the eviction murders findings and recommendations · 2013. 2. 2. · shots fired 27 “11-99 on...

ii

In Memoriam

iii

Sheriff Christianson’s Message

As you review this report, remember the noble actions of Deputy Robert Paris and

Locksmith Glendon Engert. These men were performing their profession's duties, trying to

ensure that a legal process would be served in a peaceful manner.

I will always remember the days that followed this tragedy. Person after person

commented on Glendon and Robert's personal values and how they had made a difference

in so many people’s lives and well-being. We will never forget their deaths and the

sacrifices of their loved ones.

Throughout this great nation, policing our diverse communities presents the men and

women in law enforcement with unique challenges and dangers. By examining this

incident through independent assessment and transparent analysis, the Stanislaus County

Sheriff's Department will determine how this occurred and what can be done to prevent

future tragedies.

Sheriff Adam Christianson Stanislaus County Sheriff's Department

iv

Acknowledgments

Law Enforcement After killing two people, a barricaded and heavily armed murderer presented law

enforcement personnel with significant and violent challenges for an extended time period.

Despite these dangers, the involved peace officers performed policing actions in the highest

traditions of law enforcement's rich history.

Law enforcement personnel from the following local, state, and federal policing agencies

are recognized for placing themselves in harm’s way, for offering immediate equipment

and resources, and for their efforts in addressing and investigating the incident’s

aftermath:

Alameda County Sheriff’s Office

Calaveras County Sheriff’s Office

California Department of Corrections & Rehabilitation – Parole Division

California Highway Patrol

Ceres Police Department

Hughson Police Services

Manteca Police Department

Merced County Sheriff’s Department

Merced Police Department

Modesto Police Department

Newman Police Department

Oakdale Police Department

Patterson Police Services

Ripon Police Department

Riverbank Police Services

Sacramento County Sheriff’s Office

San Joaquin County Sheriff’s Office

v

Stanislaus County District Attorney’s Office

Stanislaus County Probation Department

Stanislaus County Sheriff's Department

Tuolumne County Sheriff’s Office

Turlock Police Department

U.S. Bureau of Alcohol, Tobacco, Firearms & Explosives

Vallejo Police Department

U.S. Federal Bureau of Investigation

U.S. Marshal’s Service

Waterford Police Services

vi

Community and Public Safety Sheriff Christianson recognized that many community members were extremely important

to others’ safety and welfare during and after the incident. He commended agricultural,

business, charitable, civic, educational, employee, fire, political, religious, residential, and

service members and their organizations for making a difference in public safety.

The following Stanislaus County community policing partners are acknowledged for their

individual and team contributions:

American Medical Response

American Red Cross

Deputy Sheriffs’ Association

Loomis Armored Vehicle Company

Modesto Regional Fire Authority

Stanislaus County Community Members

Stanislaus County Community Organizations

Stanislaus County Reserve Deputy Sheriffs’ Association

Stanislaus County Sheriffs’ Supervisor Association

Stanislaus County’s Employee Association

Stanislaus County Sheriff’s Air Support Association

Stanislaus County Sheriff's Employee Foundation

Stanislaus County Sheriff’s K-9 Association

Stanislaus County Sheriff’s Management Association

Stanislaus County Sheriff's Posse Association

Stanislaus County Sheriff’s SWAT Association

Stanislaus Sheriffs’ Explorer Post No. 226

Stanislaus Sheriffs’ Team of Active Retired Seniors

Stanislaus Regional 9-1-1 Communications Center

Stanislaus Sworn Deputies Association

Critical Incident Report

Eviction Murders – April 2012 vii

Table of Contents

In Memoriam ii

Sheriff Christianson’s Message iii

Acknowledgments iv

Law Enforcement iv

Community and Public Safety vi

Critical Incident Report 1

Sheriff’s Decision 1

The Report’s Purpose 2

“A Moment in Time” 2

Stanislaus County 3

Stanislaus County Sheriff’s Department 3

Fallen Deputy Heroes 3

City of Modesto 4

Modesto Police Department 4

Fallen Officer Heroes 4

Stanislaus County Peace Officer’s Memorial 5

Line of Duty Deaths in Stanislaus County 6

The Person Responsible 7

Before the Incident 8

The Neighborhood 8

Ferrario’s Residence 8

Community Perceptions of Public Safety 11

Significant Events and Behaviors 12

Father’s Death 12

Relationships 12

Financial Problems 12

Electricity Theft 12

Vigilante Activities 12

Attempted Vehicle Theft 12


Eviction Murders – April 2012 viii

Surveillance Cameras 13

Security Door 13

Carrying Firearms on Personal Patrols 14

Membership in a Group 14

Disputes with Neighbors 14

Law Enforcement Contacts 15

Opportunities to Report 15

Eviction Process Initiated 15

Warnings of Danger 16

A Propensity for Violence 18

Five-Day Notice Posted 19

“Are you writing this down?” 19

Deputy Paris is Cautioned 19

Supervisors Notified of Warnings 19

The Critical Incident 20

Duty Assignments 20

40 Years of Law Enforcement Experience 20

Eviction Strategies and Tactics 20

Previous Experiences as Partners 20

Deputies’ Arrival and Initial Observations 20

No “Calling Cards” 21

Deputies and Locksmith Meet 21

Written Warnings 23

Enforcing the Eviction 26

A Noise is Heard inside the Residence 27

Shots Fired 27

“11-99 on Chrysler” – Two People Down 28

Rescue People Down 29

Special Weapons Teams Arrive and Deploy 29

Law Enforcement Response 30

Command Post 30


Eviction Murders – April 2012 ix

Gathering Intelligence 31

Attempts to Communicate 32

Media Activities 32

Armed and Barricaded Suspect 33

Preparing for the Police Response 33

“I Just Started Shooting Them” 38

The Fire 38

Timeline on Chrysler Drive 42

The Investigation 43

“Lying in Wait” 43

Responsibility for Fire 44

No Additional Casualties 44

James Ferrario 44

Cause of Death 44

Toxicology Report 44

Criminal History 45

California Guard/Patrol License 45

Firearms 45

The Funerals 47

Glendon David Engert 47

Robert Lee Paris Jr. 48

Findings and Recommendations 49

Before the Incident 50

During the Incident 61

After the Incident 75

List of Findings with Page Numbers 96

Before the Incident Findings 96

During the Incident Findings 97

After the Incident Findings 98

The Future 100

Authors 100


Eviction Murders – April 2012 x

Addendum 101

Glendon David Engert Eulogy 101

Robert Lee Paris Jr. Eulogy 102

Stanislaus County Sheriff’s Eviction Packet 103

Stanislaus County Sheriff’s Emergency Information Contact Form 104

Stanislaus County Sheriff’s 2012 Organizational Chart 105

Stanislaus County Sheriff’s Court and Civil Services Eviction Checklist 106

Stanislaus County Eviction Restoration Notice 107

Stanislaus County Notice of Eviction 108

Stanislaus County Notice of Restoration 109

Stanislaus County Notice to Vacate 110

Stanislaus County Writ of Execution 111

Whispering Woods Map 112


Eviction Murders – April 2012 1

Critical Incident Report On Thursday, April 12, 2012, at approximately 10:52 a.m., an eviction process was initiated

by the Stanislaus County Sheriff’s Department in the City of Modesto, California. Involved

were two uniformed Stanislaus County Deputies accompanied by a local locksmith.

James Ferrario, the resident to be evicted, was heavily armed and awaiting their arrival.

Ferrario did not respond to the uniformed deputies’ door knocks and verbal

announcements as peace officers. While the deputies took positions south and west of the

front door, the locksmith began drilling the metal security door's lock.

Shortly thereafter, Ferrario fired multiple 7.62 caliber rounds from a semi-automatic rifle

that struck and killed Deputy Paris and Locksmith Engert. Over the next 17 hours, Ferrario

remained barricaded and refused to surrender. His dangerous behavior exposed numerous

community members and peace officers to potential serious bodily injury and death.

Note: The aforementioned description, “semi-automatic rifle,” which fires a 7.62 caliber

bullet, is commonly referred to as an “assault rifle.” Ferrario possessed several types of

rifles. Throughout the report, the term semi-automatic rifle is used when referring to his use

of a 7.62 caliber semi-automatic rifle.

Sheriff’s Decision Stanislaus County Sheriff-Coroner, Adam Christianson, directed an independent review to

identify the challenges faced, decisions made, strategies utilized, and lessons learned. This

included law enforcement activities before, during, and after the incident.

This report is solely based on the documents reviewed and the interviews conducted by the

authors. As a result, the authors do not, and cannot, comment or base any conclusions on

any person’s account with whom they did not speak or any documents not reviewed.



The Report’s Purpose

The following objectives were established to meet the “transparent analysis” directed by

Sheriff Christianson:

Assess Policing Actions – Policy, Tactics and Training

Review Force Used

Acknowledge Lessons Learned

Identify Law Enforcement’s Best Practices Develop Findings

Enhance Policing Knowledge

Improve Peace Officer Awareness, Safety, and Skills

Provide Advisory Recommendations

“A Moment in Time”

Police work is challenging, demanding, difficult, and dangerous. The men and women who

serve in law enforcement are required to make split-second decisions during rapidly

changing conditions while dealing with fear, shock, startle, and surprise. Despite

thousands of hours of individual and team training, peace officers continue to encounter

situations that will tax their abilities, emotions, knowledge, and skills to the highest level of

mastery. This is the harsh reality of policing our communities. Yet, law enforcement

officers continue to risk their lives for people they will never know.

As one reads this report and develops opinions, it is important to recognize that the actions

of Deputy Paris and his partner related to this critical incident were thoroughly examined.

Acknowledging the lessons learned, this review does not represent Deputy Paris and his

partner’s public safety contributions throughout their policing careers. This is an

examination of one moment in time when Deputy Paris and his partner handled a policing

activity that each had successfully managed before.

No one should lose sight of the fact that Deputy Paris made the ultimate sacrifice while

performing a lawful action. Clearly, peace officers who read this report can easily

remember their own mistakes that could have become tragic. As you reach conclusions,

remember that peace officers are expected to be perfect in an imperfect world and are held

to the highest standards.



Stanislaus County

Stanislaus County is located in the Central Valley of California. Over 514,400 people live

and work within 1,514 square miles that consist of nine incorporated cities and 14

unincorporated communities. Wine grapes are Stanislaus County’s number one industry

followed by other agricultural products.

Stanislaus County Sheriff’s Department The Stanislaus County Sheriff’s Department (SCSD) is a full-service law enforcement

agency. When the incident occurred, the workforce consisted of over 590 full and part-

time employees assigned to civilian, correctional, and sworn positions. Patrol,

investigative, and specialized policing services are provided to a geographically diverse

county with rural and urban terrain and vast agricultural lands.

The SCSD is directed by an elected Sheriff-Coroner, Public Administrator who is assisted by

the Undersheriff. The Department is divided into two divisions; Adult Detention and

Operations. The divisions are commanded by Captains. Within the Adult Detention

Division is Court and Civil Services, which is supervised by a Lieutenant.

Note: Included in the Addendum is the Department’s 2012 Organizational Chart.

The SCSD’s Court and Civil Services is responsible for serving civil process throughout

Stanislaus County. Over the years, the SCSD has handled thousands of evictions.

Fallen Deputy Heroes Since 1967, three SCSD deputies have been killed in the line of duty:

Deputy Sheriff Harold Lee Thornton – End of Watch, Wednesday, August 23,

1967. After responding to a stabbing call, Deputy Thornton was shot and

killed.

Deputy Sheriff Bill Joe Dickens – End of Watch, Tuesday, January 27, 1970.

While responding to a bank robbery in progress, Deputy Dickens was shot

and killed.

Deputy Sheriff Robert Lee Paris Jr. – End of Watch, Thursday, April 12, 2012.

During an eviction service, Deputy Paris was shot and killed.



City of Modesto

Modesto is the 18th largest city in California and the county seat of Stanislaus County.

Surrounded by rich farmlands, Modesto ranks sixth in the state’s farm production. The city

was immortalized in the 1973 film “American Graffiti.”

Modesto Police Department The Modesto Police Department (MPD) is a full-service law enforcement agency with over

230 civilian and sworn employees. The Department provides patrol, investigative, and

specialized policing service to over 201,100 people within 37 square miles of business,

commercial, and residential neighborhoods.

Fallen Officer Heroes Since 1973, two MPD officers have been killed in the line of duty:

Officer Leo “Bobby” Volk Jr. – End of Watch, Monday, May 21, 1973. While

pursuing a fugitive vehicle, Officer Volk died in a traffic collision.

Sergeant Steve May – End of Watch, Thursday, July 23, 2009. On July 29,

2002, Sergeant May responded to an intersection to assist other officers

involved in the pursuit of a stolen vehicle. As Sergeant May entered the

intersection, his marked police vehicle was struck by the stolen vehicle

driven by the fleeing felon, resulting in massive injures from the collision.

Seven years later he died from his injuries.



Stanislaus County Peace Officer’s Memorial

Since 1935, Stanislaus County law enforcement agencies have lost 14 peace officers in the

line of duty. The victim peace officers were from the following agencies:

California Highway Patrol – Three Peace Officers

Ceres Police Department – One Peace Officer

Modesto Police Department – Two Peace Officers

Riverbank Police Department – One Peace Officer

Turlock Police Department – Four Peace Officers

Stanislaus County Sheriff’s Department – Three Peace Officers

Stanislaus County Peace Officer’s Memorial

These peace officers are honored on the Stanislaus Peace Officer’s Memorial located at the

Lakewood Memorial Park in Hughson, California. Annually in the month of May, these

policing heroes are remembered at local, state, and national ceremonies during Police

Week.



Line of Duty Deaths in Stanislaus County California line of duty peace officer deaths are divided into two categories: accidental and

felonious deaths. These deaths are tracked by the United States and California

Departments of Justice. In California, the deaths are analyzed by the California Commission

on Peace Officer Standards and Training (POST), Law Enforcement Officers Killed and

Assaulted (LEOKA) Council.

In August of 1935, the first Stanislaus County peace officer death occurred. Between 1973

and 2004, a period of 31 years, there were no peace officers killed in Stanislaus County.

However, since 2005, four of the fourteen peace officers, or 29%, have died in the line of

duty.



The Person Responsible

James Ferrario, a troubled 32-year-old adult male and former security guard, was directly

responsible for the murders of Deputy Robert Paris and Locksmith Glendon Engert.

Ferrario was described by various people as a “paranoid recluse,” who lived alone in a

residence that was being foreclosed.

James Ferrario



Before the Incident

The Neighborhood The incident occurred in a tree-lined, densely populated residential neighborhood called

Whispering Woods in the City of Modesto, California. Each two-story building has four

separate apartment homes with different floor plans. All of the buildings have two

attached garages that face the alley.

Whispering Woods Neighborhood Three Days after the Incident

Ferrario’s Residence Ferrario lived at 2141 Chrysler Drive, Apartment One. His apartment was a 780 square feet

single story unit that faced the street. The apartment building is described as follows:

Side One– A front door with a window on each side of the door.

Apartment One, Side One



Side Two – Ferrario’s master bedroom and the entrance to Apartment Two. Below

is a picture of a neighbor’s building with the same floor plan. A red arrow points to

where his master bedroom would be located.

Apartment Two, Side Two

Side Three – Two attached garages with Apartment Four above them. Below is a

picture of a neighbor’s building with the same floor plan. A red arrow points to

Apartments Four’s front door.

Apartment Four, Back Alley, Side Three



Side Four – A window in Ferrario’s second bedroom and the entrance to Apartment

Three. A red arrow points to his second bedroom.

Apartment Three, Side Four

Ferrario’s apartment had an interior common wall that separated his two bedrooms

and bathroom from Apartments Two and Three.

Note: Law enforcement terminology identifies the main entrance to a structure as Side One.

The remaining structure sides are numbered in a clockwise direction as Sides Two, Three,

and Four. The structure’s corners are identified as the One and Two Corner, the Two and

Three Corner, the Three and Four Corner and the One and Four Corner.

James Ferrario’s Residence, Apartment One

Entry into Ferrario’s home led to an open area that consisted of the dining room, kitchen,

and living room. Down the hallway there was a furnace closet and a bathroom that

separated the bedrooms. Each bedroom had a closet.



Ferrario’s Floor Plan

Example of Ferrario’s Apartment

Community Perceptions of Public Safety In previous years, Ferrario’s neighborhood was distressed and known for its criminal

activity. Community policing partnerships involving neighbors, the City of Modesto, and

the Modesto Police Department resulted in public safety improvements.



While examining the incident site, the authors noted that the Whispering Woods apartment

homes and landscaping were well-maintained. There were no examples seen of the

“Broken Window Theory” such as abandoned vehicles, automobiles parked on front lawns,

broken windows, graffiti, and trash.

Significant Events and Behaviors It was concluded that a series of events contributed to Ferrario’s violent behavior. The

following, either individually or in concert, were considered significant:

Father’s Death

Between 1997 and 2008, Ferrario lived at this residence with his father. The natural death

of Ferrario’s father in 2008 had adverse impacts on his financial stability and life. This

death resulted in Ferrario becoming estranged from his mother and sister.

Relationships

At the time of this incident, Ferrario was not known to have any social relationships.

According to investigators, the only known person that he communicated with was an

individual in the neighborhood who suffered from mental illness.

Ferrario had previously divorced his wife. For two years prior to the incident, he had no

contact with her or their daughter.

Financial Problems

Ferrario failed to pay homeowner association dues and mortgage payments amounting to

thousands of dollars. These debts resulted in foreclosure procedures with Ferrario’s home

being sold at auction. Furthermore, a lien was placed by the homeowner’s association.

Electricity Theft

Due to Ferrario’s unemployment and mounting debts, he was unable to pay for electricity.

Thus, he illegally rigged an electrical cord from a garage to his home to obtain electricity.

Vigilante Activities

James Ferrario learned to conduct armed patrols from his father. It is believed that

financial and personal problems increased his anger and paranoia and contributed to his

vigilante behavior.

Attempted Vehicle Theft

The investigation revealed that an unknown person(s) attempted to steal Ferrario’s vehicle

that was parked on the street in front of his home. The date of occurrence is unknown and

was not reported to the Modesto Police Department. This crime was another causal factor

for Ferrario to justify armed vigilante actions and to use surveillance cameras.



Surveillance Cameras

Although it is unclear when cameras were installed, Ferrario installed three surveillance

cameras to monitor activity outside his residence. One camera was installed in a tree in

front of his residence. It is believed that this camera monitored Ferrario’s front door and

yard area.

The second camera was installed in a window to the left of the front door. This camera was

stationed on the windowsill and facing the front door. It is believed that this camera

surveyed the front door, front yard, his personal vehicle, and a portion of the street.

The third camera was placed in the master bedroom window. The partner of Deputy Paris

described this camera as “tubular” with a lens approximately one inch in diameter. It was

concluded that this camera would monitor the street and adjacent yard area.

Evidence of a Surveillance System

Security Door

In front of Ferrario’s wooden front door was a reinforced metal security door. It appeared

that the door was modified to strengthen the structure. The door was powder coated white

with a metal screen of tiny holes. During daylight hours, the mesh covering enabled

Ferrario to see outside, while anyone at the door could not see inside. Furthermore, the

person outside could not determine if the resident’s front door was open or closed.



In the picture below, a hinged plate of approximately 1/8 inch steel is shown above and to

the right of the entry handle. This was added to the door as an aftermarket enhancement.

Ferrario’s Security Door

Carrying Firearms on Personal Patrols

In an ongoing effort to protect his property, Ferrario would emerge from his home during

darkness wearing military clothing with handguns holstered on each hip and a rifle carried

at port arms. Generally, this occurred each night with him walking around outside his

residence. As alarming as this was, no one called the police.

Membership in a Group

Although the investigation did not find membership or participation in a group of concern,

it was the opinion of an investigator, based on Ferrario’s behavior, dress, and weaponry,

that he was involved in “paramilitary activity."

Disputes with Neighbors

On July 13, 2006, a dispute with a neighbor resulted in a verbal threat with Ferrario stating,

"If I come out, you are going to lose." Eventually, this incident escalated into a neighbor

being sprayed with bear mace by Ferrario. Two of Ferrario's neighbors moved from the

neighborhood as a result of his security cameras being directed toward the neighbor's door

and Ferrario’s disturbing and uncomfortable personal interactions with others.

In 2007, police responded to several disturbance calls involving Ferrario and his neighbors.

These occurred on January 16, February 28, and July 30. During these service calls,

Ferrario directed verbal threats, a laser-equipped Taser, and his surveillance cameras at

neighbors. Some of these neighbors felt that Ferrario was mentally unstable. No arrests

were made in these incidents.



Law Enforcement Contacts

On 11 other occasions, Ferrario was contacted by local peace officers, as follows:

1997 – Traffic Incident, Vehicle Towed

1999 – Two Disturbing the Peace Incidents

2000 – Two Disturbing the Peace Incidents

2000 – Misdemeanor Warrant Arrest

2003 – Traffic Citation for Speeding

2003 – Violation of Court Order

2004 – Traffic Citation for Tinted Windows

2007 – Victim of a Residential Burglary

2008 – Reckless Driving Arrest

After March of 2008, no evidence was discovered that Ferrario was the subject of any

documented policing contact. It is speculated by the authors and investigators that

Ferrario’s reclusive lifestyle and paranoia coupled with previous police encounters caused

him to avoid the police.

Opportunities to Report Prior to this critical incident, various community members either learned of or witnessed

James Ferrario’s disturbing and unusual behaviors. Each person had the opportunity to

discuss, evaluate, and report Ferrario’s actions. Unfortunately, many of these incidents

were not reported to law enforcement.

Eviction Process Initiated On December 21, 2011, Ferrario's home was acquired at a trustee sale. The purchaser

never had contact with any person at the residence. The buyer hired a bonded, licensed,

and registered Stanislaus County eviction agent and process server to evict Ferrario. This

agent claimed experience with over 1,200 evictions.

On Tuesday, January 24, 2012, RT Financial Inc. was granted a Writ of Possession for James

Ferrario’s real property at 2141 Chrysler Drive, Apartment One, Modesto, California. This

was granted by the Superior Court of California, Stanislaus County, No. 672010. On

Thursday, April 5, 2012, the eviction agent contacted the Court and Civil Services of the

Stanislaus County Sheriff’s Department for service.



Note: When the court decides in favor of the landlord, a judgment is entered. If the tenant

does not vacate the property, the landlord may then request the court issue a Writ of

Possession. The Writ is directed to the Sheriff and contains a statement to the tenant: “If the

tenant does not vacate the property within five days from the date of service, the levying

officer (Sheriff) will remove the occupants from the real property and place the landlord or

their agent in possession.” The tenant then has fifteen days to contact the landlord and make

arrangements to claim any personal property left on the premises.

When the Sheriff receives the Writ of Possession and instructions from the landlord, a Notice

to Vacate along with a copy of the Writ is served on the tenant, by personal service, or

posting a copy on the property. After five days, if the property has not been turned over to

the landlord, the Sheriff requires the landlord or their agent to be present at the property.

The landlord or their agent must provide keys to make entry or make an arrangement with a

locksmith to gain access. Sheriff Deputies are not allowed to force entry, i.e., break windows,

create damage or kick doors to complete the eviction process.

Sheriff Deputies will search the property to insure the occupants are gone and allow the

landlord to change locks. The landlord is then issued a Notice of Restoration and the

property is restored to the landlord. Any personal property not claimed by the occupants

will be sold or destroyed per code.

The eviction agent was hopeful that Ferrario would vacate the property without a Writ of

Possession process. After an estimated 10 to 15 visits in-person and different written

communications by the eviction agent or his representatives, Ferrario never answered his

door or provided any written response.

Warnings of Danger During on-going efforts to contact Ferrario, the eviction agent and staff members learned

or witnessed the following that were linked to Ferrario:

Cameras – Multiple Security Video Cameras

Neighbor Conflict/Concern – Two neighbors, in close proximity to Ferrario's

residence, requested a “quiet conversation” with the eviction agent. The

neighbors were concerned that, should Ferrario overhear the conversation,

serious conflict would occur.

Firearms – Neighbors saw Ferrario with M16s and pistols.

Law Enforcement Beliefs – Neighbors said Ferrario thought he was a police

officer.

Military Experience – Neighbors believed Ferrario had military police training.

Explosives – Neighbors heard Ferrario's rhetoric regarding bombing his

neighborhood and felt that there were bombs in his garage.

Propensity to use Firearms – Neighbors recalled Ferrario saying, “You’re going

to have a firefight on your hands.”



Security Door – Described by the eviction agent as solid square tubing in front of

the wooden entry door, fortified beyond most security doors that are generally

purchased.

Security Door Slot – The eviction agent described the hatch as a "flip-up slot" and

felt that a pistol could be extended from the modified opening. In fact, he said

the slot resembled “the side of a SWAT (Special Weapons and Tactics) vehicle.”

View Inside the Security Door – Could not see inside due to the powder coating,

small holes, and wire mesh. The eviction agent said “It wasn’t like a normal

Home Depot or Lowe’s door.”

Criminal Record – The eviction agent learned that Ferrario had a criminal

history.

Certified Mail – Mailings sent to Ferrario were never acknowledged.

Writ of Possession – Posted on Ferrario’s front door.

Facebook – The eviction agent checked “James Ferrario’s Modesto Facebook”

and found a picture of a person that was believed to be Ferrario in a military

outfit with a hat covering his face.

Personal Concerns – The eviction agent was told by neighbors that Ferrario

would learn everything about the agent. They felt that Ferrario could do this as

he may be a security officer.

Note: Due to this warning, the agent checked and found no evidence of Ferrario being a

private investigator. Coincidentally, after the start of the eviction process, the agent's

personal vehicle was burglarized at his home and a bag was stolen. To date, there is no

evidence to connect Ferrario to this crime.



Automobile– The neighbors described Ferrario’s vehicle as follows:

o “Jacked-up, kind of beefy”

o “Like a cop push bar on the front”

o “Little pop-outs, tinted windows, little cop lights on the side”

Ferrario’s1992 Chevrolet Suburban

Note: The above photograph was taken after a search for explosives. The search was

conducted by the SCSD Explosives Ordinance Disposal Team with the support of local and

federal law enforcement agencies.

Ferrario’s vehicle was a 1992 Chevrolet Suburban, registered to him. The vehicle was

parked one house east of his residence.

A Propensity for Violence After considering the previous information, the eviction agent felt that a limited number of

these issues would not create personal concerns. However, the totality of the observations

made the agent believed that "This is weird." Specifically, the following caused the eviction

agent great concern:

Ferrario’s Erratic and Unusual Behaviors

Presence of Firearms

Lethal Combination of Explosives and Firearms

The agent concluded that if Ferrario was challenged, he would use violence to protect his

home and stop the eviction. For safety reasons, the agent decided to proceed with an

unlawful detainer action and involve law enforcement.



Note: While the critical incident was in progress, the agent shared this information with

MPD detectives. The agent described Ferrario's commitment: “He’s down; he’s down to go

down with the ship (Ferrario's home)."

Five-Day Notice Posted Prior to the Writ of Possession, a Court and Civil Services Deputy went to Ferrario’s

residence. After unsuccessful attempts to speak with someone inside, the Five-Day Notice

to voluntarily vacate the premises was posted on Ferrario’s front door.

“Are you writing this down?” On Wednesday, April 11, 2012, at 10:32 a.m., a day before the critical incident, the eviction

agent received a call from a SCSD Court and Civil Services Legal Clerk. The clerk advised

that the Chrysler eviction was scheduled for the next day, Thursday, at 10:55 a.m.

During their conversation, the clerk asked the agent what was known about the subject and

location. The agent gave the following information, asking, “Are you writing this down?"

“You need to tell these people that he’s been seen with M16s and other guns.”

“There’s a possibility that he has bombs in that house.”

“I know I told you guys this stuff before; this is serious.”

“The door is very strong.”

“Something doesn’t look right.”

Deputy Paris is Cautioned On the day the warnings were brought to the Legal Clerk’s attention, the clerk personally

spoke with Deputy Paris. The clerk told Deputy Paris of the eviction agent’s concerns for

Stanislaus County Sheriff’s personnel and the clerk’s personal concern about the high

likelihood for danger at Ferrario’s location. The clerk added, “Be very cautious,” and

Deputy Paris replied, “Whatever.”

Supervisors Notified of Warnings The Court and Civil Services Legal Clerk prepared the SCSD’s Eviction Packet and brought

the eviction agent’s warnings to the attention of the Supervising Legal Clerk. This civilian

supervisor told the clerk to make the Court and Civil Services Sergeant aware of the

dangers.

The clerk then met with the sergeant. After reviewing the documents, the sergeant

instructed the clerk to put the warnings in bold black print on the packet's first page and

use a red marking pen to circle them. The clerk complied with the sergeant's instructions

and left the packet for Deputy Paris and his partner to review the next morning.



The Critical Incident

Duty Assignments On Thursday, April 12, 2012, Deputy Paris and his partner reported for duty at the Court

and Civil Services. They received their Eviction Schedule that consisted of five evictions to

serve with a route and specific time schedule.

40 Years of Law Enforcement Experience Deputy Paris and his partner had 40 years of combined law enforcement experience. Paris

had served the SCSD for 15 and one-half years, 13 years as a Deputy Sheriff, and two and

one-half years as a Reserve Deputy Sheriff.

Deputy Paris’ partner had 24 and one-half years of law enforcement experience, serving 17

years as a SCSD Deputy Sheriff, and seven and one-half years as a Police Officer with two

different police departments. The partner also had seven years of military experience.

Eviction Strategies and Tactics Three weeks prior to this incident, Deputy Paris and his partner began working together.

During this time period, their daily duties consisted of using the following patrol

techniques:

Seniority – Since Deputy Paris was the Court and Civil Services senior eviction

deputy, he would serve as the contact deputy.

Contact and Cover Responsibilities - Deputy Paris would make contact with the

people being evicted while his partner would assume a guarding position.

Verbal Tactics – Deputy Paris’ partner described their communication style as,

“We negotiate and sell the eviction,” rather than “Throwing someone out.”

Previous Experiences as Partners During prior policing activities, Deputy Paris and his partner’s tactics were likely

influenced by the following:

Use of Force – No force was used during their time as partners.

Vacancy Factor – According to Deputy Paris’ partner, most of the buildings they

entered were vacant and they encountered no problems at approximately 80%

of their evictions.

Deputies’ Arrival and Initial Observations At approximately 10:50 a.m., Deputy Paris and his partner arrived at the 2100 block of

Chrysler Drive. Since Deputy Paris had an afternoon dental appointment, this was their last

scheduled eviction for that day.



Ferrario’s Apartment, 2141 Chrysler Drive, Apartment One

At previous eviction sites, the deputies sometimes made observations that might present

safety concerns. On this day, the deputies noted the following:

Absence of Blight – No Abandoned Vehicles, Discarded Furniture, Littered

Trash, etc.

Advertisements – No Real Estate Advertising Signs

Appearance – Lawns Mowed

Dogs – No Barking Dogs

Movers – No People Moving In or Out

No “Calling Cards” In August of 2012, Deputy Paris’ partner was interviewed by the media at an awards

ceremony. He described the activity and neighborhood: “There is always some calling card

that people are upset with you. We didn’t have any of that.”

Deputies and Locksmith Meet The deputies had arrived just before their scheduled eviction time of 10:55 a.m. They

unknowingly drove past Ferrario’s automobile, parking their unmarked SCSD vehicle one

house west of Ferrario’s home.



While the deputies sat in their parked vehicle, Locksmith Engert approached on foot.

Engert had parked his white utility van in front of Ferrario’s residence. During their

conversation, the deputies and locksmith confirmed that they had both just arrived and had

not observed activity at the involved building. The landlord was expected at any moment,

and none of them had keys for Ferrario’s residence. Deputy Paris recommended that they

start.

Location where Locksmith Engert Parked



The photograph below shows the following:

White Ford – Deputies’ Unmarked SCSD Vehicle

Ferrario’s Home – Blue Arrow

Ferrario’s Automobile – A green arrow identifies a partial view of the front of

Ferrario’s vehicle.

2100 Block Chrysler Drive

Written Warnings Not noticing the security cameras that were mentioned in the eviction paperwork, the

deputies and the locksmith walked together toward the home. As they were walking, the

deputies speculated that Ferrario may have vacated the premises and taken the cameras.

As they crossed the lawn and approached Ferrario’s home, Deputy Paris carried the

paperwork. Although the only hint of possible problems was the written notes on the

following SCSD documents, Deputy Paris’s partner would later acknowledge that these

warnings made the deputy feel “unsettled:”



Eviction Schedule – Written by the Legal Clerk on the Eviction Schedule was

“Be very cautious”, and “Is going to have problems.”

SCSD Eviction Schedule (Red circles added by authors.)

During the time that Deputy Paris had been in the Court and Civil Services, this was the first

occasion for the clerk to write written warnings on the form. According to the clerk, the

following comments were written twice, once on the form’s front and again on the back.

They were written in bold black print and circled in red “squiggly” lines with asterisks “so

they would stick out”. A rectangular box was drawn around these warnings:

“Very Weirdo”

“Lots of Video Cameras Even in the Trees”

“It May Take a While to Open Lock”

“Extremely Secure Security Door”

“Ex-Military/Militia”

“Be Cautious”

“Multiple Guns M-16 Type”

“Violent”

Note: The fire destroyed the majority of the eviction packet.



The above checklist recovered from the eviction scene had the following questions with

these written answers:

Are you aware of any weapons on the premises? – “Yes – multiple guns M-16 type”

Are the tenants violent? – “Possibly”

The original eviction paperwork carried by Deputy Paris was damaged by the fire.

However, some words were still visible in the photographs above and below.

SCSD Eviction Checklist



SCSD Eviction Paperwork

Note: A review of the damaged document and statements from the partner of Deputy Paris

and the Legal Clerk provided clarification of the written warnings.

Enforcing the Eviction Deputy Paris repeatedly announced “Sheriff’s Department” and knocked on the front

security door with his ASP baton. Simultaneously, Deputy Paris noticed the first camera in

the living room’s windowsill to the left of the front door (Side One), while his partner

observed a second camera in the master bedroom’s windowsill on the structure’s west side

(Side Two). The camera next to the front door was described by Paris’ partner as being

small like a box, about the size of a “couple packs of cigarettes.”

The security door was locked and no one acknowledged Deputy Paris’ requests. After

waiting approximately 15 seconds, the locksmith started to drill. Deputy Paris was

standing a couple of steps behind the locksmith while his partner had established a cover

position approximately six to ten feet from the building’s southwest corner (One/Two

Corner).



A Noise is Heard inside the Residence The locksmith was partially kneeling and pushing heavily against the drill. After

approximately 30 seconds of drilling, the locksmith stopped and told the deputies that he

had heard someone or something inside the apartment house. Due to the drill’s noise, the

deputies had not heard anything. They waited another 30 seconds, and no sounds were

heard. The locksmith then resumed drilling.

Drill used by Locksmith Engert

Shots Fired As the drilling continued for approximately 30 more seconds, gunshots erupted from a

semi-automatic rifle, and bullets came through the security door. During Ferrario’s initial

shots, the investigation found that the wooden front door was open. Deputy Paris’ partner

described the gunfire as follows:

“Two or three shots, like high-powered rifle, semi-automatic, they were

aimed rounds.”

“Snap, like fingers snapping.”

“This guy was pin-point, I mean he executed them.”

The following events then occurred:

Deputy Paris was shot first, receiving fatal gunshot wounds to his head and

torso. Bullets penetrated both the front and rear panels of Deputy Paris’

body armor. As Paris fell mortally wounded to the ground, he continued to

receive additional gunshots wounds from Ferrario.

Locksmith Engert was shot next. He attempted to run away from the

doorway and collapsed with fatal gunshot wounds on the walkway between

the residence and Chrysler Drive.



At least twelve 7.62 caliber rounds were fired by Ferrario. Two vehicles that

were parked on Chrysler Drive were struck, causing property damage only.

One vehicle was parked in front of Ferrario’s residence while the other was

parked across the street.

Vehicles Damaged by Ferrario’s Gunfire

“11-99 on Chrysler” – Two People Down Immediately, Deputy Paris’ partner returned gunfire. Being aware of the surveillance

camera that could identify the deputy’s position to the armed suspect, a kneeling position

was taken next to a tree, expecting the suspect to emerge from the front door shooting.

The deputy made a radio broadcast of “11-99, Officer Down, Shots Fired, Two Down at

2201 Chrysler.” The deputy requested SWAT and warned arriving officers of the suspect

using a high-powered rifle.

Note: An “11-99” radio broadcast indicates that an emergency is in progress and the peace

officer(s) needs immediate assistance.

Arriving within a minute of the help call were Modesto Police Department personnel. The

MPD was assisted by California Highway Patrol and SCSD personnel. As these officers were

deploying and starting rescue operations, Deputy Paris’s partner suffered a non-gunshot

related foot injury. This deputy went to the ground and low-crawled north. This route

passed Ferrario’s master bedroom window and led to the alley behind the building. The

deputy immediately provided pertinent location and weapon information about Ferrario to

the officers in the alley.



Rescue People Down Both Deputy Paris and Locksmith Engert appeared to have suffered multiple gunshot

wounds. They were motionless and unresponsive to the first responders’ questions.

Modesto Police officers and detectives developed and initiated a tactical plan to rescue

Locksmith Engert and Deputy Paris. As the rescue team moved forward, surveillance

cameras were spotted, and the first rescue attempt was aborted.

The second rescue attempt involved using a marked MPD police vehicle for cover. A

ballistic shield was placed inside the vehicle’s front passenger window for additional

protection. The rescue team consisted of MPD personnel and a SCSD detective.

MPD Rescue Vehicle

Upon reaching the victims, the rescue team first extracted Engert and then Paris from the

front of Ferrario’s residence. The victims were then transported by ambulance to a nearby

hospital. Sadly, both victims were pronounced dead by medical personnel.

Special Weapons Teams Arrive and Deploy Special Weapons and Tactics Teams (SWAT) from SCSD and MPD were the first teams to

arrive and deploy. The MPD SWAT team became the primary team with SCSD assisting.

As the critical incident continued, additional SWAT teams, armored vehicles, and bomb

squads from surrounding law enforcement agencies arrived, as well as agents from the

Federal Bureau of Investigation. During the incident, these allied SWAT teams were used

for community member evacuation, outer perimeter staffing, and other tactical missions.



SWAT Personnel Responding and Deploying

Law Enforcement Response Law enforcement personnel from MPD, California Highway Patrol (CHP), and SCSD

responded. As the incident continued, over 200 peace officers from other local, state, and

federal agencies arrived to assist.

Command Post The MPD’s Command Post (CP) and their SWAT Tactical Operations Center (TOC) were

established at the intersection of Chrysler Drive and Prescott Road. The FBI later

established an intelligence area, utilizing the Whispering Woods Leasing Center’s

administrative offices, at the northwest corner of the intersection.

Command Post Location Chrysler Drive Prescott Road



Gathering Intelligence As the barricade situation continued to unfold, investigators from various law enforcement

agencies worked in concert with the primary MPD investigators. The following

information about Ferrario was quickly being collected:

Contact Information – Social Media

Family Members – Names and Locations

Motive

Telephone Numbers – Mobile and Residential

During investigators’ interviews, various neighbors and witnesses said that Ferrario

possessed the following:

Ammunition Stockpiles

Armor Piercing Ammunition

Automatic Assault Weapons

Body Armor

Explosives

Fortified Cinderblock Bunker

Gas Masks

Grenades

Helmets

High-Powered Scoped Rifles

Police Radio Scanner

Utilities Stolen from another Resident

They also described Ferrario as armed and dangerous, delusional, military trained and

reclusive. He had also been seen patrolling the neighborhood at night in military fatigues

with a rifle. Prior to this incident, none of the aforementioned information was ever

reported to the MPD or any other law enforcement agency.



James Ferrario

Note: The above photographs were discovered during MPD’s investigation. The comments

were added by an investigator and the date of the photographs could not be determined.

Attempts to Communicate Using different communication options during the first six hours of the incident, numerous

law enforcement efforts to talk with Ferrario were made. Ferrario disregarded all requests

and refused to communicate, ignoring all attempts to end this violent confrontation

peacefully.

Media Activities After arriving at the scene, the SCSD Sheriff addressed the media. Throughout the incident,

MPD and SCSD Public Information Officers (PIO) provided periodic media briefings.



Media Site

After the incident started, media helicopters created safety and tactical concerns.

Eventually, federal law enforcement efforts, resolved the problems.

Helicopter Media

Armed and Barricaded Suspect During the next eleven hours, Ferrario refused to negotiate or surrender. Despite attempts

to initiate a dialogue through telephone and verbal efforts, he remained armed and

barricaded.

Preparing for the Police Response After the incident, it was found that Ferrario had anticipated law enforcement personnel

making a forcible entry. This was due to the discovery that Ferrario undertook the

following actions:

Moved household furniture and his refrigerator to block access into his

apartment.



Placed sheets in front of window openings and closed the window coverings.

Applied an ace bandage to his knee to deal with a wound. Due to chemical

agent residue being located under this bandage, it was concluded that a

chemical agent projectile caused the injury.

Dressed in a protective manner wearing body armor and a gasmask. The gas

mask was worn to endure chemical agents.

Ferrario’s Body Armor

Ferrario’s Gas Mask

Inserted pieces from a plastic block into his clothing to create ballistic panels

that would add padding and protection from gunfire.

Used his bathtub as a bunker for additional protection.



Arranged an arsenal of firearms so that these weapons were easily

accessible. The semi-automatic pistols and rifles were outside the bathtub

and the bolt-action rifles and shotguns were propped up in the bathtub.

Ferrario’s Firearms

Staged ammunition for his firearms in the bathroom so that the greatest

amounts of bullets were for the semi-automatic pistols and rifles.

Positioned ammunition in the bathroom to accommodate reloading.

Ferrario’s Ammunition

Loaded multiple ammunition magazines into cloth carriers with a sling for

convenient and immediate movement to other locations.



Ferrario’s Cloth Carriers

Ammunition inside a Cloth Carrier

Placed in the bathroom hundreds of rounds of rifle ammunition in a cooler.

Stored multiple water bottles in the bathroom to remain hydrated.

Additionally, the water bottles could be used as ballistic protection and first

aid for chemical agents.



Ferrario’s Water Bottles

Broke through his master bedroom’s wall that separated his home from the

adjoining apartment (Apartment Two).

Created access through Apartments Two and Three’s common interior wall

for unobserved movement. Since Apartments Two and Three both had

interior stairs, this allowed access to the second story of both apartments.

Ferrario’s Breaching Point between Apartments One and Two



As the barricade incident continued, SWAT observed movement in the upper areas of

Apartments Two and Three. Tear gas was then deployed as a strategy to force Ferrario

down to his apartment where a telephone had been inserted by a police robot.

“I Just Started Shooting Them” At 7:35 p.m., Ferrario used a cellular telephone to call the Stanislaus Regional 9-1-1

Communications Center. He identified himself as “Jim” and said that he was calling from

“2141” (Ferrario’s address was 2141 Chrysler Drive).

As their conversation continued, the 9-1-1 operator told Ferrario it was hard to understand

him and asked if he was wearing a headset. Ferrario replied “yes,” and he was asked to

remove it.

Note: It is speculated that Ferrario was wearing a gas mask to defeat the chemical agent that

had been inserted into the building.

Ferrario then provided the following information to the operator:

Location – He was in Apartment Two.

Movement – He was moving between Apartments One, Two, and Three.

Request – If a pizza was delivered to Apartment Two’s front door, Ferrario

would call back and come out after eating the pizza.

In three separate statements during the telephone call, Ferrario acknowledged

responsibility for shooting Deputy Paris and Locksmith Engert. The following are his

admissions:

“This is Jim at 2141, Number Four, I apologize, I thought it was a burglar and

I just started shooting them.”

“I thought it was a burglar and I shot. They woke me up out of a dead sleep.”

“I apologize, I didn’t know it was the police until after I started shooting

because I thought it was a burglar, I do apologize.”

The 9-1-1 operator immediately notified her supervisor. The information was then

provided to investigative and tactical personnel.

The Fire At 9:15 p.m., ten hours after the barricade incident began, a fire occurred in one of the

upstairs adjoining apartment homes within Ferrario’s building. The fire dwindled and then

reignited. By 10:00 p.m., the structure was almost fully engulfed by flames. At 10:32 p.m.

Modesto Fire Department (MFD) was able to safely start extinguishing the blaze with

water.



Below are pictures of the fire in Ferrario’s building starting with the early stages and

ending with the building completely destroyed.

Fire Starts Upstairs

Fire Reignites



2141 Chrysler Drive, Fully Engulfed in Flames

At approximately 4:00 a.m., fire had destroyed the entire building. An inner perimeter was

established and a “Code Four” was broadcast.

Note: A “Code Four” is a verbal radio message indicating that a situation no longer requires

additional assistance.



Aerial View

Street View from Chrysler Drive



Timeline on Chrysler Drive

April 12 & 13, 2012 Timeline - 2141 Chrysler Drive

5:25 p.m. – Throw Phone Deployed7:22 p.m. – Explosive Charge Detonated on Front Door

7:35 p.m. – Ferrario Called 9-1-1

10:50 a.m. – Deputies Arrived10:51 a.m. – Locksmith Met

10:54 a.m. – Shots Fired

11:07 a.m. – Rescues Began11:16 a.m. – Evactuations Started

11:25 a.m. – Tear Gas Started

9:15 p.m. – Fire Observed Upper Floor10:32 p.m. – Fire Dept. Deployed Water

4 a.m. – Building Destroyed

10:50 – 10:55 a.m. 11:05 – 11:25 a.m. 5:25 – 7:35 p.m. 9:15 p.m. – 4 a.m.



The Investigation

Modesto Police Department and SCSD agreed that MPD would conduct the investigation.

The investigation was assigned to the MPD Homicide Unit.

On Friday, April 13, 2012, Ferrario’s body was discovered in Apartment One. He was

deceased and seated in his bathroom with his back against the tub enclosure. At that time,

the cause of death was unknown and he was unrecognizable due to the fire.

Investigation in Progress

“Lying in Wait” The MPD investigation reported that Ferrario retreated to the bathroom at an

undetermined time. It was concluded that Ferrario was preparing for law enforcement to

enter, barricading himself inside the bathroom with the following items:

Ammunition – Over a Thousand Rounds

Ammunition Bandoliers - Several

Body Armor – “Make-shift” around Legs and Lower Extremities

Body Armor – Vest Covering his Torso

Rifle Rounds – Hundreds in an Ice Chest



Clothing – Several Layers below his Waist

Firearms – 30

Handguns – Armed with Three Semi-Automatic Pistols

Rifles – Several in Bathtub Directly behind Him and an AK-47 Rifle next to his

Body

Unidentifiable Firearms – 10, Destroyed by Fire

Gas Mask – Next to his Body

Tactical Gear – Wearing Several Items

On Sunday, April 15, 2012, at 4:50 p.m., three days and six hours from the initial shooting,

the crime scene investigation was completed.

Responsibility for Fire When the “Eviction Murders” report was completed, the MPD investigation concluded that

Ferrario started the fires. At this time, the U.S. Department of Justice, Bureau of Alcohol,

Tobacco, Firearms and Explosives’ agents have not determined the fire’s cause and origin.

No Additional Casualties During the incident, approximately 100 to 150 people were safely evacuated from the

Whispering Woods neighborhood to a nearby school staffed by American Red Cross

personnel. This evacuation included adults and children who were moved from their

homes to a position of safety.

James Ferrario

Cause of Death The autopsy determined that Ferrario was an adult male, born on March 26, 1967. At 45

years of age Ferrario died from self-inflicted gunshot wounds, the first to the abdomen and

the second to the head. Non life-threatening injuries included a gunshot wound to his foot

and bruising from a ferret (tear gas) round striking Ferrario in his lower abdomen and

possibly on his knee.

Toxicology Report A heart blood sample from James Ferrario was acquired by the Stanislaus County Coroner.

The findings revealed the following:

Drugs – None Detected

Ethyl Alcohol – None Detected



Criminal History Ferrario had been involved with various criminal justice agencies. These encounters

resulted in Ferrario being detained, cited, arrested and convicted for different California

Penal and Vehicle Code violations. The charges included burglary, contempt of court,

driving on a suspended license, driving unlicensed and buying/receiving stolen property.

Furthermore, failures to appear in court resulted in arrest warrants being issued.

Ferrario was previously convicted of a felony, receiving stolen property. This felony

conviction would have prevented him from purchasing a firearm(s) and from obtaining a

security guard license. Through legal representation, Ferrario’s felony conviction was

reduced to a misdemeanor. Thus, he was issued a security guard license which allowed

him to legally purchase handguns and inherit his father’s rifles.

California Guard/Patrol License On April 16, 2007, the California Department of Consumer Affairs, Bureau of Security and

Investigative Services issued a Guard/Patrol License to Jim Richard Ferrario. The license

had a related firearm permit.

Firearms At the time of the incident, Ferrario had 30 firearms in his residence. The identifiable

weapons consisted of semi-automatic rifles, handguns, hunting rifles, and shotguns, and

over 1,000 rounds of ammunition. The investigation determined that Ferrario legally

acquired the following revolver and semi-automatic pistols:

Kahr Model PM9094A – 9mm – Pistol, Purchased January 29, 2008

Glock Model 22 – 40 Cal, Purchased August 6, 2007

Smith & Wesson Model 340 – 357 Magnum, Purchased July 6, 2007

Glock Model 26 – 9mm, Purchased January 15, 2006

Glock Model 27 – 40 Cal, Purchased December 9, 2005

At Ferrario’s residence, the investigators discovered the following firearms:

Norenko SKS 7.62 Caliber Rifle

Unknown Brand AR – 15

Unknown Brand and Caliber Semi-Automatic Rifle

Husqvarna – 270 Rifle

Winchester – 30/30 Rifle

Winchester – 22 Caliber Rifle

Unknown Type/Caliber Rifle

Unknown – 22 Caliber Rifles (2)

Unknown – 22 Caliber Bolt Action Rifle



Harrington & Richards – 20 Gauge Shotgun

Unknown – 410 Gauge Shotguns (2)

Winchester – 20 Gauge Shotgun

Glock – 40 Caliber Pistols (2)

Glock – 9 Millimeter Pistol

Kahr – 9 Millimeter Pistol

Llama – 22 Caliber Pistol

Smith & Wesson – 357 Magnum Revolver

Note: Although 30 firearms were discovered, only 14 rifles and six handguns were

identifiable. Due to the fire, ten additional firearms could not be identified by brand, type or

caliber.



The Funerals

Separate viewing, funeral, and burial services were conducted for Locksmith Glendon

David Engert and Deputy Sheriff Robert Lee Paris Jr. Thousands of people, including

community members, family, friends, loved ones, and peace officers, paid respect and

gratitude to these brave men for their service to others and ultimate sacrifice.

Glendon David Engert During funeral services on Saturday, April

21, 2012, Glendon Engert, 35 years of age,

was remembered by family and friends as a

loyal husband, caring son, and kind friend.

He was described as a quiet man, smart and

humble at the same time, a man who loved to

travel, was an avid reader and liked to camp

with friends in the Sierras, “a truly gentle

soul.”

A devout Jehovah's Witness, Glendon

worked as a surveyor. When the economy

worsened, he became a locksmith to earn a

living. In relation to his new profession, he

shared his concerns for people with church

members. An elder at his church said, “He

would sometimes talk about the unkempt

and damaged homes he would encounter on

calls or while changing locks on homes for

banks.”

Glendon Engert is survived by his wife,

parents, his brother, sister-in-law, and many spiritual friends.



Robert Lee Paris Jr. On Friday, April 20, 2012, the

funeral service for Deputy Paris, 53

years of age, was attended by over

5,000 people. Three thousand

community members and

approximately 2,000 peace officers

paid their respects. Dignitaries

included California Governor Jerry

Brown and other local, county, state

and federal dignitaries.

During the service Robert Paris was

remembered fondly by a long line of

co-workers, friends and family for

his hard work, love of the outdoors,

and great friendship. All of the

speakers talked of Paris' love for

fishing and hunting trips into the

wilderness of Stanislaus County, Northern California and Colorado. Each year he would

save vacation time so that he could work as a hunting guide in Montana.

Sheriff Christianson described Deputy Paris as a brave, compassionate, dedicated, and

understanding law enforcement officer who would assist others with a helping hand. The

Sheriff then thanked Paris for “making a difference.”

Robert Paris is survived by his mother, father, brother, sister, daughter, and son.



Findings and Recommendations

The following findings and recommendations are offered for review. This information is

based on contemporary law enforcement policies, procedures, and practices. Best policing

practices were determined using ethical, legal, proper, and safe professional standards that

enable law enforcement to protect and serve in the highest tradition.

For the reader’s convenience, a numerical list of all findings can be found on page 96. The

findings and recommendations are grouped into the following three sections:

Before the Incident

During the Incident

After the Incident

The following words of caution are offered. Whenever the reader reviews a finding and

associated recommendation, they are reminded that the policing actions taken were either

appropriate, subject to improvement, or inappropriate.

At first glance, the reader may conclude that all recommendations and findings indicate

improper law enforcement actions. This is not correct, as a number of the decisions were

consistent with valid police practices. However, this does not discount that lessons were

indeed learned.

This review did not specifically examine the actions of other law enforcement agencies.

However, within the report, the efforts of law enforcement agencies directly or indirectly

involved in this incident were identified. Not all findings are followed with a

recommendation.

Throughout information gathering, the authors identified specific safety issues. These

concerns and recommendations were shared with Stanislaus County Sheriff Christianson.

The Sheriff is acknowledged for not waiting for the report’s completion to implement

change. Furthermore, the initial findings and recommendations remained in the report

with comments on actions taken.

The following words, “Experience is a cruel teacher,” were reflected in a previous critical

incident report by a supervisor. Acknowledging the lessons learned in this report will

provide civilian and sworn law enforcement leaders and personnel the opportunity to use

firsthand knowledge to improve effectiveness and safety.



Before the Incident

Finding No. 1 — Protecting His Castle

Ferrario knew the date and approximate time that SCSD personnel would complete the

eviction. This provided Ferrario an opportunity to contemplate his misfortune and plan for

law enforcement’s arrival. Ferrario gathered equipment and weapons to stop the process,

and indications were he was “lying-in-wait” for the deputies.

Recommendation:

The notification process has since been modified by SCSD to withhold specific information from the person being evicted. It is imperative that Court and Civil Services personnel and supervisors continue to assess if further change is necessary.

Finding No. 2 — Tactical Concerns Known and Reported

It was reported by more than one SCSD employee that there were concerns with Paris’

behavior during evictions. At some previous evictions, the following actions were

documented, observed, or reported to Court and Civil Services supervisors:

Not advising dispatch of field status and location.

Not drawing and exhibiting his firearm when entering and searching a

building.

Not having his mobile telephone on silent mode during building searches.

Carrying eviction paperwork in his hand(s) during entering and clearing

operations.

Moving throughout a building too quickly versus a more cautious pace.

Ignoring small rooms and closets when searching.

Searching with a hand(s) in his pocket(s), talking on his mobile telephone, or

whistling.

During the following interactions with other co-workers and supervisors, Paris’ attitude

toward safety and supervision was sometimes described as disrespectful or negative:

When notified by communication personnel to log on, he responded, “Oh

why, nothing ever happens.”

The day before the Chrysler Drive eviction, the clerk alerted Deputy Paris to

potential dangers. Paris replied, “Whatever.”



Prior to field duties on the day of the incident, Deputy Paris and other deputies

received policy training from supervisors due to recent administrative failures.

In response to a supervisor’s question as to whether the material was

understood, Paris retorted, “Clear as mud.”

Recommendation:

It is recommended that the SCSD Sheriff direct a review to determine if the leadership, management, supervision, and training strategies were insufficient to address Paris’ performance.

Finding No. 3 — A Problem was Brewing

Various employees had expressed concerns regarding the Court and Civil Services’ work

environment. It was voiced that conflict existed and there were differences of opinion

between personnel in the deputy, sergeant, lieutenant, and captain ranks.

It was difficult to determine who was right and who was wrong. Differences between the

sergeant, lieutenant, and captain existed as to effective leadership, personnel, and training

strategies and they experienced problems in addressing the issues in a united manner.

Unfortunately, blame and finger-pointing were occurring among employees and

supervisors. Some issues were unresolved and may have been contributing factors to

events before and during the critical incident.

Recommendation:

The Sheriff should determine if further Court and Civil Services personnel and operational changes are necessary. This should include a field procedures assessment when handling civil processes including evictions, money seizures, etc.

Finding No. 4 — “Retirement Center”

Civilian and sworn employees provided varying descriptions of a Court and Civil Services

assignment. Their remarks included statements that only senior personnel could work

there, this was a “dumping ground” for underperforming personnel, “evictions is not real

cop work,” and many people thought of it as a “retirement center.”

Recommendation:

In many law enforcement agencies, personnel reach conclusions as to why one assignment is easier or has more perks than another. The responsibility for SCSD is to continue their current assessment of how evictions are being handled, whether the leadership and supervision at the Court and Civil



Services is working effectively together and if the lessons learned from this incident are being addressed.

Finding No. 5 — Patrol Experience

More than one employee commented that Court and Civil Services procedures were not

conducive to effective and safe field operations. Specific examples cited were supervisory

comments that primary eviction responsibilities would be impacted whenever Court and

Civil Services deputies assisted other law enforcement, or SCSD personnel handling

emergency calls or enforcement activities.

It is acknowledged that supervisory comments are sometimes misinterpreted. No matter

how these messages were delivered or defined, the employees’ beliefs underscore issues

that require attention and clarification.

Recommendation:

Clarify to Court and Civil Services personnel their options when they hear an

emergency call or see a law enforcement officer involved in a pedestrian or

vehicle stop.

Assign an experienced patrol sergeant to Court and Civil Services.

Note: At the Sheriff’s direction, this personnel change has occurred.

Conduct frequent and joint Court and Civil Services civilian and sworn

employee briefings, meetings, or training sessions. The civilian supervisor

and sergeant should be present and the lieutenant and captain should attend

periodically. This will enhance vertical communication and ensure a better

understanding of the challenges faced and practices utilized.

Consider whether certain Court and Civil Services field activities should be

assigned to the Operations Division.

Direct the Court and Civil Services’ Lieutenant and Captain to participate in

field ride-alongs with deputies to assess their knowledge, practices, and

skills.

Ensure that the sergeant has the necessary time to complete administrative

duties, observe field performance, and personally supervise selected day and

nighttime field activities.

Direct the Court and Civil Services Sergeant to occasionally work evening

hours to inspect evening civil process activities. The Court and Civil Services

Lieutenant and Captain should consider ride-alongs during these hours.



Finding No. 6 — The Eviction Schedule

Different Court and Civil Services employees expressed frustration with the Eviction

Schedule’s management and requirements. They felt that the schedule’s route and time

constraints did not allow for potential problems.

When these problems occurred, rushing to complete the current eviction and responding to

the next would generally impact the quality of their performance. Furthermore, they were

concerned that the unknown occurrence in police work was not being given the proper

weight and was causing risk liability and safety problems.

It is recognized that civil process presents leadership and time management challenges to

the agency and responsible supervisors. However, these employee comments require

further evaluation.

Recommendation:

Further review of the Eviction Schedule’s objectives and time factors should occur. A communication strategy should be developed that takes into consideration employee concerns and unanticipated field issues. It should also be determined if schedule compliance may cause unsafe driving practices.

Finding No. 7 — Supervisory Meetings

The Court and Civil Services Eviction Sergeant did not regularly attend supervisory

meetings. It was difficult to determine if Adult Detention supervisory meetings addressed

the issues encountered in this review.

Recommendation:

It is recommended that Court and Civil Services civilian and sworn supervisors attend scheduled divisional meetings with their lieutenant and captain. Furthermore, it would be beneficial for the Court and Civil Services’ Sergeant, who supervises civil process operations to attend the Operations Division’s supervisory meetings.



Finding No. 8 — Restricted Duty Status

It was reported that a Court and Civil Services Sergeant had a field duty restriction.

According to Court and Civil Services personnel, this restriction was being violated with the

awareness of superiors. Since this finding, a weekly notice of restricted duty personnel is

distributed to command personnel for compliance.

Recommendation:

It is recommended that the Department determines if managers are aware which employees have duty restrictions, if they properly understand their restrictions from field operations, and if personnel are complying with SCSD regulations.

Finding No. 9 — Documenting Performance

On six different occasions, the Court and Civil Services Sergeant worked with Deputy Paris.

During these field operations involving 50 to 60 evictions, the supervisor observed officer

safety concerns. Although the sergeant notified the lieutenant, Paris’ performance

deficiencies were not documented and no action plan was developed between the

supervisors.

Recommendation:

It is recommended that SCSD’s Lieutenants and Captains ensure that first line supervisors understand the importance of documenting issues of concern. The initiation of a Performance Improvement Plan (PIP) may have improved Paris’ officer safety practices and performance. Furthermore, notification to the sergeants’ superior is extremely important in mutually crafting and initiating leadership and training strategies for subordinate employees.

Finding No. 10 — Risk Assessment

After the eviction agent’s warnings, the Court and Civil Services Clerk immediately

contacted the Court and Civil Services Sergeant. The sergeant gave the clerk specific

instructions to print the warnings in bold black ink and circle them in red on the eviction

paperwork. The clerk was then told to give this paperwork to the assigned deputies.

The sergeant shifted the analysis, risk assessment, and decision making to subordinate

personnel. The supervisor clearly should have ensured that the following occurred:

Perform risk assessment and tactical analysis.

Meet with the deputies and develop an operational plan with public and

officer safety considerations and options.



Direct a background check on Ferrario, including criminal record, firearm

information, location history and wants/warrants.

Approve a SCSD Risk Assessment matrix.

Assign a field supervisor and additional deputies if SCSD specialized or SWAT

personnel were determined not to be an option.

Consult qualified SCSD personnel who could provide tactical options for

surveillance, detention, arrest, and use of force strategies.

Advise the lieutenant of the warnings and provide an operational plan

approved by the sergeant.

Prior to the eviction at Ferrario’s residence, both the Court and Civil Services Senior

Eviction Deputy (Paris) and the Sergeant had a duty obligation to create an effective and

safe operational plan. Based on the reported information, additional background

investigation and alternative tactics were necessary. If strategies could not be developed

within this short time period, Ferrario’s eviction should have been rescheduled.

Recommendation:

It is imperative that Court and Civil Services personnel involved in civil process receive training on background information checks, risk assessment, and operational plan development and approval. Also, the sergeant should review the risk assessment and operational plan, and personally meet with the assigned deputies.

Finding No. 11 — Warnings

The deputies and sergeant did not effectively react to the verbal and written warnings.

This complacency problem has a long history in the police profession and is considered a

redundant causal factor in peace officer assaults and deaths.

Recommendation:

At all times, personnel should continually check and counter-check each others’ actions. This ensures that common and repetitive police behavior does not lead to inattention to detail and unsafe practices. The maintenance of the Department’s tactical standards is a must for all Department leaders and requires further assessment within the Court and Civil Services.

Finding No. 12 — Data Bases

Information data bases were not utilized by Court and Civil Services personnel to check

Ferrario’s criminal and firearms history. If Ferrario’s criminal record had been checked, it

would have revealed multiple arrests and five registered handguns.



Recommendation:

Conduct an assessment to determine if Court and Civil Services personnel are thoroughly trained to utilize internal and external law enforcement record systems. Furthermore, improve the division’s guidelines to ensure that necessary information is gathered and reviewed prior to field activities.

Finding No. 13 — Employee Data Base Suggestions

Following the incident, Court and Civil Services personnel assessed past practices of not

utilizing data base information. Consequently, the SCSD’s Integrated Criminal Justice

Information System (ICJIS) is now used to verify information. This system contains

incident history, dates, and facts going back to 1980.

After further Court and Civil Services personnel meetings, the following employee

suggestions were made to enhance effectiveness and safety:

Provide access to all SCSD databases from in-car computers and work

stations.

Ensure that the Automated Firearm System (AFS), California Law

Enforcement Telecommunications System (CLETS) and Cop Link are

available and utilized.

Recommendation:

These suggestions are best policing practices and should be approved. Additionally, Court and Civil Services personnel need to maximize the use of premise history information.

Finding No. 14 — Communicating with Dispatch

When the “11-99” radio broadcast for help with shots fired was initiated, the dispatcher did

not recognize the unit involved. Consequently, this created additional confusion and stress

among communication personnel. Commendably, dispatch personnel quickly overcame

this problem, and proper radio transmissions occurred.

Among Court and Civil Services personnel, there were differences of opinion as to whether

eviction and other field activities should be reported to the Communications Center. On

this day, Deputy Paris and his partner did not report the following to dispatch:

Start of Duty Tour

Unit Call Sign

Eviction Activities throughout the Morning

Arrival on Chrysler Drive



As a result of this incident, Court and Civil Services personnel are now following Department policy and communicating with dispatch.

Recommendation:

Supervisors must be reminded to frequently check radio activities of subordinate personnel.

Finding No. 15 — Supervisory Attention to Field Activities

Civilian and sworn personnel were aware of the deputies’ failures to comply with SCSD

radio procedures.

Recommendation:

Supervisors need to be reminded that noncompliance with required policing

practices can create problems.

Note: Prior to this report’s completion, Court and Civil Services Deputies began contacting

dispatch regarding all activities.

Finding No. 16 — An Appointment

Deputy Paris had asked for the afternoon off. This request was approved, granting Paris an

end-of-watch time after finishing Ferrario’s eviction. Paris’ need for time off may have

influenced Deputy Paris and his partner’s decisions.

Recommendation:

A time-honored practice in police work is “slowing-it-down.” Unless there is a need to save lives, this tactical strategy is extremely effective in policing operations. Creating an understanding and being able to implement this valuable concept during field operations remains a challenge for all law enforcement agencies. During briefing, debriefing and training activities, instruction on “rushing–in” versus “slowing–it-down,” should be reinforced.

Finding No. 17 — Follow-Up

The SCSD Eviction Schedule issued to Deputy Paris and his partner revealed the eviction

agent’s first name and telephone number and the attorney’s first and last name with a

telephone number. Had the deputies telephoned the eviction agent to acquire additional

safety information or to corroborate the clerk’s written warnings, this may have caused the

deputies to reconsider their approach and contact strategies.



Recommendation:

When eviction documents indicate a potential for violence, it is recommended that Court and Civil Services personnel and supervisors thoroughly assess the danger, ensuring that all sources of information are reviewed.

Finding No. 18 — One Veteran to Another

Prior to arriving at Ferrario’s residence, Deputy Paris and his partner reviewed the eviction

paperwork. They noted the following information about Ferrario:

Emotionally Disturbed and Delusional

M-16 Type Weapons

Prior Military Experience

Deputy Paris’ partner felt that he might be able to verbally persuade Ferrario to voluntarily

vacate the location. This was based on the deputy’s prior military training and consistent

with their previously agreed response tactics of “selling the eviction.”

It is acknowledged that peace officers must be able to solve problems through effective

communication skills. However, in this incident, the deputies’ belief may have had an

adverse effect on their recognition of reported dangers and selection of tactics.

Recommendation:

Stanislaus County Sheriff’s Department personnel must recognize when someone is not properly using a successful policing strategy. Placing an emphasis on any tactical option must include a balance of skills so that a peace officer will not underestimate high-risk threats to public and officer safety. Proactive leadership actions and realistic and verifiable training must continue to address unsafe policing behaviors.



Finding No. 19 — Educating our Stakeholders

Locksmith Engert parked his vehicle in front of 2141 Chrysler Drive, Apartment One.

Parking directly in front of a call for service location is not a recommended policing

practice. Engert’s vehicle was a white utility van and his parking location was described as

“directly” in front of Ferrario’s residence.

Locksmith Engert’s Van

Recommendation:

Consider whether a SCSD educational program should be offered to locksmiths within Stanislaus County. If approved, this ongoing community policing business partnership could include a meeting(s) with selected training topics. The training topics could consist of SCSD’s civil process procedures, practical safety tips, and “If you see something, say something.” This may include where to safely park and meet the deputies.



Finding No. 20 — No Indicators

When Deputy Paris knocked on Ferrario’s front door in the presence of his partner and the

locksmith, the MPD investigation found no other indicators that anyone was inside the

residence. However, this investigative finding does not discount or dismiss the written

warnings that had been provided.

Note: Refer to Finding No. 74, “If the Suburban is there,” page 88 for clarification regarding Ferrario’s

personal vehicle.

During policing activities, approaching a building or standing in front or near a door or

window is considered a dangerous position. Generally, this area is referred to as a “high

threat zone.” This zone is defined as an area that is controlled by a criminal‘s field of vision

and gunfire.

During this review, a MPD investigator made the following statement. “If knock and notice

applies, so does everything else when it comes to following safety practices.” These words

underscore a policing standard that needs to exist during similar policing operations.

Recommendation:

Peace officers should be reminded that approaching a residence and standing in front of a door or a window can be dangerous. This should only be done when a peace officer is totally satisfied that no threats exist. An exception would be exigent circumstances that require immediate action.



During the Incident

Finding No. 21 — Watching the Police

While searching Ferrario’s front room, crime scene investigators located a surveillance

system. This included several video recording devices and a television monitor. The items

appeared to have been operational.

Recommendation:

Technology has made surveillance systems inexpensive and simple to acquire and

install. Law enforcement personnel are reminded that their actions and words may

be surreptitiously monitored by criminals.

Finding No. 22 —“I Think Someone’s In There”

After drilling for approximately 30 seconds, Locksmith Engert told the deputies that he

thought he heard a noise inside the residence. He then said, “I think someone’s in there.”

The deputies and locksmith waited approximately 30 seconds and not hearing further

noise, the locksmith resumed drilling. Approximately 15 seconds later, gunfire erupted

through the front door.

Considering the totality of information, written warnings regarding Ferrario, the presence

of security cameras, the noise, and the locksmith’s belief that someone was inside, the

deputies should have stopped and relocated everyone to a position of advantage. At this

point, further tactical analysis was necessary.

Recommendation:

Law enforcement should ensure that training scenarios involve decision-making with rapidly changing conditions. Scenarios requiring critical thinking, movement, reassessment, scanning, tactical breathing, and use of force options will better prepare peace officers for today’s challenges.

Finding No. 23 — Rescues

When reviewing the totality of the circumstances, especially the public and officer safety

challenges, the rescues of Engert and Paris were initiated in a timely manner. Valor in law

enforcement’s highest traditions was demonstrated by MPD and SCSD personnel who

extracted Engert and Paris.



The police equipment shown below was used during the coordinated rescues. It is

important to note that a ballistic shield protected the rescue team and the driver. The

moving vehicle, traveling west, placed a blocking barricade between Ferrario and the

rescue team.

The MPD is commended for having a ballistic shield in every sergeant’s car and other

investigative and specialized vehicles. Consequently, this vital protective equipment was

immediately available for field deployment.

Rescue Vehicle with Shield

Inside Rescue Vehicle with Shield



Rescue Vehicle Ferrario’s Vehicle

Rescue Scene

Recommendation:

It is recommended that law enforcement personnel receive recurrent rescue training. This training should include scenarios where personnel clearly understand tactical options for exterior and interior rescues.

Finding No. 24 — Rescue Training

Before the rescues, it was noticed by some of those present that a few first responders

appeared confused and traumatized. This is understandable as they were seeing people

critically injured and down in a high threat zone. Additional comments from more than one

person centered on the fact that some peace officers were not confident or familiar with

immediate action and rapid deployment tactics.

When responding to people down, law enforcement has learned the following lessons:

First responders will generally be patrol and investigative personnel.

First responders must understand how to immediately develop an

operational plan and lead the rescue.

First responders need ballistic protection, i.e., body armor, helmets, shields,

etc.

"Cover fire" or "suppressive fire" is often misunderstood.

The rescue of people is a perishable skill that requires verifiable training.

Locksmith Engert’s

Position

Deputy Paris’ Position



First responder training has been found to be non-existent or inadequate at

more than one California policing agency.

Recommendation:

It is imperative that Stanislaus County's law enforcement leaders direct an evaluation of their agency's capabilities and knowledge in rescuing people down. Consideration should be given to joint training exercises that involve local, state and federal agencies to ensure the best understanding of available equipment, rules of engagement, and use of force options.

Finding No. 25 — Rescuing Deceased People

It was learned that some officers involved in the rescues felt that Deputy Paris was

deceased. Despite these beliefs, these officers willingly risked their lives in the recovery of

Locksmith Engert and Deputy Paris.

Recommendation:

Stanislaus County law enforcement leaders should implement person down rescue training. During this training, the following questions should be thoroughly answered:

Do we rescue obviously deceased community members/peace officers?

How do we justify risking lives to recover obviously deceased persons?

Finding No. 26 — Information from Another Incident

One of the primary officers in the rescues of Locksmith Engert and Deputy Paris said that

he had previously reviewed the “The Minkler Incident.” This officer felt that the knowledge

he gained about the murders of a Fresno County Deputy Sheriff and a Reedley Police Officer

in the City of Minkler, California, 2010, enhanced his personal policing abilities, decision-

making skills, and tactical performance during this crisis.

The Fresno County Sheriff’s Office is acknowledged for sharing this lesson with the law

enforcement profession. Local, state, and federal law enforcement officers have

consistently attributed their safety to learning from someone else’s incident.



Recommendation:

Policing leaders should continue to determine how to share critical incident information. Consideration should be given to a mandated review by supervisors of contemporary reports that identify policing behaviors and strategies, especially when community members and peace officers are killed.

Recommended reports are the “Independent Board of Inquiry into the Oakland Police Department,” March 21, 2009, where four peace officers were murdered in a single incident, and the recently mentioned “The Minkler Incident.” This learning activity should not be limited to California incidents.

Finding No. 27 — Private Armored Vehicle

When the call for help was broadcast, Loomis Armored Vehicle employees were monitoring

a police scanner. They responded and offered their vehicle as a rescue resource. Although

not utilized by on-scene law enforcement personnel, this action by Loomis is commendable.

Recommendation:

Maintaining policing partnerships and working together with the armored car industry can often times enhance public and officer safety. The following considerations are offered:

Conduct meetings with the armored car industry. These meetings can be facilitated by a detective commanding officer with the participation of a robbery detective(s). Attendance of other Department personnel can be determined.

Ensure that tactical information is gathered regarding the capabilities of a private armored vehicle. These facts must be shared with first responders and specialized personnel.

Note: On February 28, 1997, during the “Bank of America Shootout,” Los Angeles Police

Officers used a private armored car to successfully rescue community members and

wounded police officers.

Finding No. 28 — Radio Broadcasts/Transmissions

According to Communications Center personnel, numerous radio requests for updated

information occurred. These requests significantly congested radio traffic. Despite these

challenges, Communications personnel effectively handled this crisis.

Recommendation:

Periodic briefing reminders concerning radio discipline should be provided. Communications personnel should make updated broadcasts. This will



reduce unnecessary radio transmissions and give responders information, including the address, gunfire direction, high-risk areas, etc. To assist this effort, it is suggested that computer information or a white board be used within the Communications Center to reference and update incident information.

Finding No. 29 — Medical Emergencies

Although not directly related to the critical incident in-progress, some community

members within the police perimeter experienced medical emergencies. Police and fire

efforts were instrumental in rescuing these people in a timely manner and facilitating

emergency medical aid.

Recommendation:

Public safety departments must be prepared to handle multiple medical emergencies incidental to the ongoing critical incident.

Finding No. 30 — Community Members in Harm’s Way

Modesto Police Department personnel are commended for their heroic efforts in

evacuating community members from the high-threat zone. Below is a photograph of an

apartment wall near Ferrario’s residence that was breached by MPD personnel to relocate

community members to safety.

Breaching Point by MPD SWAT



Finding No. 31 — The Right Decision

Due to the incident occurring within MPD’s policing boundaries and the emotional impact

on SCSD personnel, it was determined that MPD would be the lead law enforcement agency.

Sheriff Christianson is recognized for accepting and supporting this decision.

Recommendation:

Stanislaus County law enforcement leaders should continue to discuss and train for future incidents where policing authority and responsibility can be multi-jurisdictional. The ability to make the best decision during a crisis situation is paramount to the effectiveness and safety of the public and police personnel.

Finding No. 32 — Working Relationships

During and after this incident, it was noted that Stanislaus County local, state, and federal

public safety leaders were successful in coordinating efforts. This unique strength is a

reflection of their commitment to service, preparation efforts, and professionalism.

Recommendation:

Continue to maintain effective working relationships that will enable varied public safety agencies in an emergency to wisely deploy personnel and resources. Furthermore, joint meetings and training exercises will provide a strong foundation for future success.

Finding No. 33 — Command Staff Teamwork

The SCSD Sheriff immediately responded to the scene. Due to numerous complicated and

demanding challenges, SCSD command staff personnel efficiently divided field and station

leadership responsibilities. This enabled the Sheriff to deal with the pressing issues of

Locksmith Engert and Deputy Paris’ murders. Furthermore, the Operations Division

Captain, who was on a day off, is acknowledged for immediately responding to direct

station activities.

The recent and unfortunate accidental duty death of SCSD Crime Analyst Technician, Mary

Donahou, in December of 2011, provided experience in dealing with one of the most

difficult tragedies in law enforcement. This knowledge was effectively used to immediately

address personnel and operational issues by command staff personnel.

Recommendation:

All SCSD personnel should continue to receive periodic training on reactions and responsibilities when a Department employee loses his or her life.



Finding No. 34 — Resources Impacted

As public safety personnel arrived, ingress and egress was adversely impacted due to

police units blocking the street. This hampered the movement of responding emergency

vehicles.

Recommendation:

Stanislaus County law enforcement personnel should receive training on parking police vehicles at critical incidents. This training should include separate staging areas for anticipated responders - fire, medical, service organizations, etc., to prevent problems. The following are training considerations:

Identify a staging area for police personnel and vehicles. Identify a separate staging area for fire personnel and equipment. Assign an officer and eventually a supervisor to manage police

personnel ingress and egress. Identify response routes to the critical incident and determine if

different ingress/egress will require multiple postings. Use an available Department or ICS form to properly document

agency, first and last name, rank, serial number, mobile telephone number, and specialized equipment and skills of each person arriving.

Determine if responding personnel are wearing readily identifiable police uniforms and have appropriate safety equipment.

Advise personnel of the radio frequency being utilized. Direct responding personnel where to properly position their

vehicles. Compose squads/teams with a supervisor to receive missions. Create squads that are composed of peace officers from the same

policing agency when staffing permits. Assign a supervisor or senior officer to supervise each squad.

Finding No. 35 — Command Post Location

The Command Post was established at the intersection of Chrysler Drive and Prescott Road,

11 buildings east of Ferrario’s residence. If Ferrario had exited his home and reached

Chrysler Drive, and discharged his firearm eastbound, command post and responding

personnel would have been subjected to gunfire.



Recommendation:

Establishing the command post on Prescott Road either south or north of Chrysler Drive would have been better. To the north there were two possible locations, a mobile home park on Prescott Road north of the Whispering Woods Estates and a church at the corner of Prescott and West Rumble Roads. To the south there was a church on Prescott Road, south of Peace Drive.

Church - Prescott and West Rumble Roads, Northwest Corner

Church - Prescott Road south of Peach Drive

At a minimum, the command post should not have been able to be seen by anyone on

Chrysler Drive. First responders and supervisors should receive periodic reminders to



select effective locations and when necessary, immediately move the command post from

an unsafe to a safe location.

Finding No. 36 — ICS Vests Not Worn by PD Personnel

As the incident progressed and local, state, and federal peace officers continued to arrive, it

was reported that Command Post personnel were not wearing Incident Command System

(ICS) vests.

Incident Command Vests

Recommendation:

At previous critical incidents in California, the practice of not wearing ICS vests has occurred too often. The following practices are considerations:

Vests – Easily Accessible ICS Guidelines – In each Vest’s Pocket Reference Guidelines – Utilized Supervision – Are personnel being directed to wear vests? Training – Are vests worn during training exercises?



Finding No. 37 — Peace Officer Bill of Rights

As the incident progressed, getting tactical information from Deputy Paris’ partner was

important. Due to this deputy’s gunfire exchange with Ferrario, the deputy was entitled to

attorney representation during interviews.

Since the deputy’s attorney could not arrive immediately, the MPD lead detective did an

outstanding job in obtaining critical information without violating the deputy’s rights. This

was done through a telephone conference call involving the attorney, the deputy, and the

investigators.

Recommendation:

Law enforcement investigators should consider using this strategy when time is of the essence.

Finding No. 38 — Verifying a Caller was Ferrario

At approximately 7:35 p.m. the lead investigator was told that a person representing

himself as Ferrario had called the 9-1-1 Regional Communications Center. As a result of

this telephone call, the following was revealed:

The person on the telephone, later determined to be Ferrario, was calling

from a cell phone.

The Communications Center operator was not able to call back due to

canceled cell phone service. Due to the discontinued service, only outgoing

emergency 9-1-1 calls could be made.

The caller requested a pizza and admitted to shooting “them.”

A digital copy of this conversation was e-mailed to the MPD lead investigator. The

investigator provided the information to other detectives for immediate action. These

detectives then directed an emergency lights and siren response to contact Ferrario’s

mother.

Local and federal efforts to re-establish service to Ferrario’s phone were unsuccessful.

Recommendation:

While a critical incident is in progress, investigators must be contemporary and creative in using technology to quickly verify information.



Finding No. 39 — The Caller was Ferrario

At approximately 11:20 p.m., MPD investigators located Ferrario’s mother at a friend’s

home near San Francisco, California. Ferrario’s telephone call to the 9-1-1 Regional

Communications Center was played for the mother and her friend. Although the mother

was unable to confirm the voice, the friend said it was Ferrario.

The investigative efforts used by MPD to locate the mother, arrange a meeting, and confirm

the caller’s identity are commendable.

Finding No. 40 — Media Helicopters

After the incident started, media helicopters created safety and tactical concerns. Initially,

local law enforcement requests to vacate the airspace were refused by a television news

director. Eventually, FBI agents working with the Federal Aviation Administration (FAA)

resolved the problem.

Recommendation:

As soon as possible, secure airspace should be established. It is in the best interest of local law enforcement to add this procedure to any pre-established checklist or procedures.

Command post and SWAT supervisors should have a current roster of media contacts with names, titles, and business/mobile telephone numbers. This information should be audited and maintained by the agency’s press information personnel. Also, local law enforcement should be aware of how to contact FAA or FBI personnel during on and off-duty hours.

Finding No. 41 — Press Information Officers’ Suggestions

After speaking with various SCSD personnel, including the Department’s Press Information

Officer (PIO), the following suggestions were identified:

Information Checks – The PIOs conducted a discussion with the incident

commander each hour to determine what information was available for

release.

Media Telephone Calls – In this incident, one PIO felt it was beneficial to

answer calls while responding to the situation. This afforded an opportunity

to provide initial information and to describe future efforts that would be

taken by law enforcement media representatives.

PIO Rotation – Working effectively together, the MPD and SCSD PIOs

alternated the management of scheduled press conferences.



Clothing – During the press conferences, rain occurred. Unfortunately, one

PIO did not have foul weather gear.

Recommendation:

The preceding lessons learned and strategies are worthy of consideration. Additionally, if it is decided that two agencies will rotate PIOs for scheduled press conferences, it is imperative that the rotating PIOs attend each other’s presentations to ensure consistency.

It is recommended that the SCSD PIO conduct scheduled media meetings at a SCSD facility. The frequency of these meetings should be decided and consideration given to highlighting various Department initiatives and solving mutual concerns.

Finding No. 42 — Initial Press Statement

During the incident’s initial moments, the SCSD Sheriff provided media information

regarding chemical agent deployment. Shortly thereafter, it was learned that this

information was incorrect.

An analysis of this information found no significant bearing on the incident’s management.

Furthermore, this was later resolved by law enforcement media personnel.

Recommendation:

During critical incidents, the volume of information initially presented to first responders is overwhelming and may be inaccurate. As information is communicated throughout the agency’s chain of command, there can always be errors and misunderstandings. All law enforcement agencies are reminded to assess information prior to media release



Finding No. 43 — The Robot

The MPD SWAT effectively used a robot to check Ferrario’s vehicle, to enhance fields of

vision, to communicate, and to move Ferrario’s furniture away from a window and door.

These uses reduced risk to the public and peace officers present.

Ferrario’s Vehicle being Checked for Explosives

Recommendation:

If not already available, it is recommended that Stanislaus County law enforcement agencies individually acquire robots. During discussions with SWAT personnel, it was learned that an armor-plated bobcat tractor capable of stopping .50 caliber bullets would be beneficial for tactical options during future incidents. If not affordable, consider mutually purchasing this equipment for countywide utilization.



After the Incident

Finding No. 44 — Surrender was not an Option

Ferrario was prepared for an extended barricade incident with law enforcement. He was

heavily armed with multiple firearms, hundreds of rounds of ammunition, body armor, gas

masks, and other supplies to support his refusal to surrender peacefully. Furthermore,

these actions are indicative of a person willing to die.

Finding No. 45 — Ferrario Described as…

During media and MPD interviews, the following words by various people in describing

Ferrario:

“Aggressive” “Odd”

“Angry” “Only Left Home at Night”

“Combative” “Paranoid”

“Confrontational” “People Out to Get Him”

“Deranged” “Recluse”

“Erratic” “Rude”

“Increasingly Isolated" “Threatening”

“Intimidating” “Weird”

“Jerk” “Wore an Old Security Uniform”

“Lived Like a Survivalist” “World was Out to Get Him”

Finding No. 46 — Letter Corroborates Ferrario Behavior

After the incident, an anonymous letter was received by the primary MPD investigator

regarding Ferrario’s background. The letter substantiated the investigator’s following

beliefs:

Ferrario was emotionally distraught.

Ferrario was on the verge of joining people who agreed with his views and

were involved in vigilante activities.



Recommendation:

This underscores the importance of reviewing correspondence involving a case of this nature. Investigators should be attuned to drawing appropriate conclusions when information dovetails with other facts.

Finding No. 47 — Explosives

Although neighbors speculated that Ferrario kept explosives, only a few packages of M-80

fireworks were found in his residence. No other explosives were discovered in Ferrario’s

home or vehicle. The combined efforts of local and federal explosives personnel during and

after the incident were commendable.

Finding No. 48 — Origin of Fire

At approximately 9:15 p.m., a fire started in Ferrario’s building. The fire began in a second

story apartment. It stopped and then restarted a few minutes later.

It is speculated that Ferrario started both fires. This is supported by the fact that Ferrario

had broken through the wall to gain access to the residence where the fire started.

It has not been determined exactly how the fire started. However, fire investigators found

that the fire’s cause and origin was not electrical or gas. Furthermore, the primary MPD

investigator working with local fire and federal law enforcement personnel conducted

testing. This examination determined that the MPD tear gas canisters could not start a fire.

Recommendation:

At the time this report was published, the federal investigation as to cause and origin had not been completed. When the federal report is finished, it should be reviewed.

Finding No. 49 — Outstanding Public Safety Efforts

Everyone who reviews this report should acknowledge the outstanding public safety

efforts of fire and police personnel. With the cooperation of community members, people

were safely evacuated and no one else was seriously injured or killed.

Recommendation:

This is a classic example of how important training is to public safety personnel. Stanislaus County fire and police leaders should continue to assess their training programs and conduct more joint exercises with integrated Incident Command System exercises.



Finding No. 50 — Community Leadership

In the days following the incident, the Sheriff met with community members to answer

questions and address concerns. This was a proactive effort to calm the community and

share information.

Recommendation:

Timely responses to public concerns are key cornerstones for community policing partnerships. When incidents of this magnitude occur, countless lives are impacted. It is recommended that law enforcement leaders carve time from their schedules to meet with community members and organizations to encourage people to report suspicious behavior.

Finding No. 51 — The Investigation

MPD investigators working with local and federal investigators conducted a thorough

investigation requiring extensive staffing hours. The following actions by investigators are

worthy of being mentioned:

Maintained a protected crime scene for three and one-half days during rainy

conditions.

Established two crime scenes, one inside and one outside the structure.

Determined that no bullet holes were found in Ferrario’s front door. This

indicated that the front door was open when Ferrario fired through the

security door.

Conducted over 250 interviews.

Developed a review of Ferrario’s life and issues that influenced his behaviors.

Worked diligently to corroborate information with Whispering Woods

residents who currently and previously resided there.

In December 2012, approximately eight months after the incident, MPD’s investigation was

provided for review. It was noted that sections of the investigation remain “open.”

Recommendation:

An investigation of this magnitude is not completed quickly. Any agency faced with a similar incident must commit multiple resources in a timely manner to properly gather evidence and information.



Finding No. 52 — Working Effectively Together

During three days of processing the crime scene, the MPD effectively assigned two

detectives as the primary and secondary Crime Scene Managers. Utilizing local, state, and

federal law enforcement personnel is an example of best policing practices.

Investigators from the following agencies efficiently processed over 500 evidentiary items

from the complex crime scene:

Modesto Police Department

Modesto Regional Fire Authority

Stanislaus County District Attorney’s Office

U.S. Department of Justice – Bureau of Alcohol, Tobacco, Firearms and

Explosives

U.S. Department of Justice – Federal Bureau of Investigation

Crime Scene Investigation at Ferrario’s Front Yard and Building



Finding No. 53 — Communication Needs

The Director of the 9-1-1 Regional Communications Center cited the recent murders of

Locksmith Engert and Deputy Paris as an incident that could have been more effectively

managed with a new communication tower. The installation will address the following

issues:

Accessibility – Improved

Communications – Coordination between Service Agencies

Consolidation – Four Transmission Sites become One Site

Direct Benefits – City of Modesto and Stanislaus County

Emergency Generator Power – Potential Use

Environmental Report - Favorable

Financial Savings – Eliminates Rent Payments

Security – Enhanced

Power Supply System – 24-hour Emergency Operation

Recommendation:

This project should be approved.

Finding No. 54 — Court and Civil Services Radio Frequency

A Court and Civil Services supervisor recommended that an individual radio frequency be

established for civil activities. It was felt that this frequency could be monitored by a Court

and Civil Services Clerk with a “hot line” to the Regional 9-1-1 Communications Center.

Recommendation:

This recommendation should be reviewed. If established, it is imperative that civilian personnel receive radio training. Since Court and Civil Services personnel sometimes conduct policing activities during non-business hours, consideration should be given to who would monitor this frequency.

Finding No. 55 — Police Work is Dangerous

During trauma debriefing sessions of SCSD civilian and sworn personnel and their loved

ones, various individuals expressed shock that a peace officer working the Court and Civil

Services could lose their life. There was a perception that policing tragedies only occurred

in high-risk patrol and specialized law enforcement activities. Comments included the

following:

“This is not supposed to happen.”

“This should not be happening to those working at Court and Civil Services.”



“Not a hook and book assignment.”

“Can rest on my laurels there.”

“Can take it easy there.”

Recommendation:

Stanislaus County Sheriff’s Department leaders at all policing ranks should frequently check their agency’s pulse to ensure that the frequency of directed, initiated, and requested activities does not permit complacency to develop in all assignments.

Finding No. 56 — Ballistic Protection

Although SCSD maintains a body armor replacement calendar, Deputy Paris’ body armor

replacement date had passed. This oversight was both a system and personal failure.

Deputy Paris’ body armor was not designed to stop Ferrario’s rifle ammunition. Most

peace officer body armor does not stop 7.62 caliber rifle ammunition. The Sheriff was

notified and without delay directed a review of the body armor replacement schedule.

Recommendation:

A quarterly review of safety equipment replacement dates should be established and a safety equipment data system developed. This would identify approaching expiration dates so that equipment can be ordered and replaced for ballistic helmets, body armor, traffic safety vests, etc.

Finding No. 57 — Ballistic Helmets and Shields

Stanislaus County Sheriff’s Department issues ballistic helmets to all patrol operation

deputies. It was found that some deputies in the Court and Civil Services did not have a

ballistic helmet.

It was also learned that a Court and Civil Services supervisor did not recognize a need for

ballistic helmets and shields. This supervisor believed that sworn personnel in Court and

Civil Services would not encounter situations requiring this equipment.

Recommendation:

Regardless of assignment, it is recommended that all SCSD personnel working plainclothes or uniform assignments be issued and required to have available body armor and a ballistic helmet. Policy should clearly state when wearing the ballistic helmet is mandatory versus optional.



Consideration should be given to replacing current helmets with a minimum Level Three-A ballistic helmet equipped with a civil disorder face shield. This helmet would provide gunfire and personal protection.

Based on insights from SCSD personnel, an audit and personal inspection of issued ballistic helmets and shields should determine the following:

Do personnel possess helmets and shields issued initially? Are supervisors addressing the culture of not using safety equipment? Are supervisors ensuring the availability and encouraging the use of

safety equipment? Do personnel receive training on how and when to use this

equipment?

Finding No. 58 — “Dragon Skin”

A recent body armor development by Pinnacle Armor in Fresno, California, claims to have

successfully defeated 7.62 caliber rifle rounds. This company states that the flexible

“Dragon Skin” armor provides “resistance against armor piercing handgun, shotgun slug,

fragmentation, and full puncture/thrust resistance all in one.”

According to Wikipedia (http://en.wikipedia.org/wiki/Dragon_Skin), “In Fresno,

California, a police department commissioned the purchase of Dragon Skin for its officers

after a vest stopped all the bullets fired during a test, including .308 rounds from a sniper

rifle and 30 rounds from a 9mm MP5 fired from five feet away. Ninety-eight federal, state,

and local law enforcement officers witnessed the SWAT test. The armor also stopped 40

rounds of PS-M1943 mild steel-core bullets from an AK-47 along with two hundred

9 mm FMJ military ball bullets fired from a submachine gun.”

Recommendation:

Stanislaus County law enforcement agencies should examine the viability and practicality of “Dragon Skin.”

Finding No. 59 — Building Entry and Search Equipment

At the time of the incident, it was found that Deputy Paris did not have a flashlight.

Furthermore, it was learned that some SCSD Court and Civil Services deputies do not

utilize building entry and search equipment.

http://en.wikipedia.org/wiki/Dragon_Skin



Recommendation:

The proposed Court and Civil Services building approach, entry, and search training should include awareness of equipment that enhances safety. These items may include doorstops, a mirror, and rope, and should be easily accessible.

It would also be beneficial to determine if Operations Division personnel possess and utilize similar building entry and search equipment. Furthermore, a safety inspection of all SCSD personnel in field assignments should occur for mandated and optional equipment such as additional ammunition, ballistic helmet, back-up firearm, reflective safety vest, trauma bandage, etc.

Finding No. 60 — Back-Up Deputy

It was learned that civil process deputies handle field activities that involve money seizures

at various businesses. These enforcement contacts generally occur during evening hours at

bars and liquor stores where robberies and other crimes are not uncommon.

Related to these duties, the following areas of concern were cited by Court and Civil

Services personnel:

Late Evening Hours – A supervisor said this was the most productive time to

seize larger amounts of money.

Plainclothes – A supervisor recommended that these details could be

conducted in this attire.

Angry People – Many times, people became emotional and upset due to their

money being seized.

Single Deputy – The counting of money by a single deputy is unsafe and

tempts others to commit a crime.

False Accusations – When only one deputy is present, people can claim that

the money count is inaccurate.

Open Areas – When money counts were not done in a private area, the

deputy was sometimes exposed to challenging behaviors.

Mixed Messages – Sometimes civil process deputies were advised that the

patrol radio frequency should not be used for this enforcement activity.

Criminal Activity – Deputies were not encouraged or mandated to conduct a

premise history check, wants and warrants verification or narcotics and vice

intelligence determination for drugs, gambling, money laundering, etc.



Recommendation:

It is recommended that money seizure practices be reviewed. This field activity should be handled by at least two uniformed deputies with notification to dispatch. If staffing permits only one uniformed Court and Civil Services Deputy, a uniformed field deputy should be requested.

Finding No. 61 — Court and Civil Services Training

It was determined that sworn Court and Civil Services personnel require additional

building approach, entry and search training. The Court and Civil Services supervisors

believed that the California Commission on Peace Officer Standards and Training’s (POST)

Basic Course and SCSD’s in-service training programs met these needs. This was not a

correct perception.

Recommendation:

It is recommended that Court and Civil Services deputies attend all field training activities provided to patrol deputies and receive additional first responder training on building approach, entry, and search.

Finding No. 62 — Tactics Training

After reviewing Deputy Paris and his partner’s actions related to Ferrario’s eviction, it was

determined that tactical training is necessary.

Recommendation:

This training by SCSD personnel should include decision-making and policing tactics. Furthermore, the training should be documented by date, time, topic, and trainer for each deputy.

Finding No. 63 — Introducing Startle and Surprise

This incident involved rapidly changing conditions of extreme stress that challenged

policing abilities, decision-making skills, and lethal use of force. Training with Simunition

rounds realistically creates shock, startle, and surprise and measures performance.

Recommendation:

The SCSD managers and trainers responsible for training must ensure that deputies are exposed to scenarios that present changing behaviors under stressful conditions. An emphasis must be placed on realism that requires immediate tactical decision-making with consideration for ethical, legal, proper, and safety issues. This includes training exercises that address when



to use force and the pros and cons of a specific physical or verbal tactical option.

Finding No. 64 — Working Together

After interviewing the involved fire and police command personnel involved, it was

recognized that perceptions of operational effectiveness differed. Although this happened,

it did not adversely impact the incident’s conclusion. This is corroborated by the fact that

only one structure burned and there were no additional serious injuries or deaths.

When local, state, and federal law enforcement leaders, and fire managers cooperate to

improve safety at critical incidents, change and improvement occurs. It was found that

Stanislaus County fire and police personnel are working together to establish joint training

exercises. In August, 2012, a planning meeting for an “Active Shooter” training scenario

was held. In light of recent incidents throughout our nation, these actions by the following

Stanislaus County public safety agencies and personnel are commendable:

Ceres Police Department, Deputy Chief

Modesto Police Department, Chief

Modesto Regional Fire, Chief

Turlock Fire Department, Chief

Turlock Police Department, Chief

Stanislaus County Sheriff’s Department, Sheriff

Recommendation:

The following are offered for consideration for Stanislaus County fire, police and sheriff personnel:

Establish a Critical Incident Task Force chaired by the Stanislaus County Sheriff, formalizing interagency cooperation and training for future critical incidents.

Enhance a clear understanding of fire and law enforcement’s needs and response guidelines during major multi-jurisdictional incidents.

Conduct quarterly training sessions with effective information sharing.

Address issues of communication, who is in charge, who has responsibility, etc.

Assess if standard definitions - jurisdictional department, primary authority, support unit, etc., can be adopted to eliminate confusion.

Develop immediate action rapid deployment scenarios where fire and police train together.

Recognize public safety capabilities and emergency response protocols for the fire and police agencies.



Conduct exercises where effective real-time communications between fire and police are demonstrated. This must be followed by a debriefing, including as many participants as possible, that concentrates on improvement and lessons learned.

Confirm that training includes pre-staging and actual staging of fire and police resources, including specialized resources from both agencies - explosive, paramedic, SWAT personnel, etc.

Draft and initiate operational plans that involve joint efforts under a single or joint incident command system during the exercise.

Establish defined command and control systems. Ensure that the fire and police leaders are able to communicate in real

time. Ideally, separate command posts should include a liaison representative from both agencies.

Cross-training exercises should occur semi-annually.

Finding No. 65 — E-Learning

It was found that civil process employees in the Court and Civil Services were not trained in

a systematic manner. There was no evidence of a training calendar or documentation

when training occurred.

During the latter part of 2012, SCSD developed and implemented a new electronic training

process. This E-Learning training can be individually accessed by SCSD employees. The

system includes SCSD’s guidelines, policies, procedures, and other relevant documents.

This proactive effort will significantly improve the dissemination of mandated training

information to a policing agency that has alternating shift schedules and geographic

challenges. The system creates accurate training records to ensure that everyone has

received contemporary training in critical subject areas.

Finding No. 66 — Procedure Manual

While reviewing a recent Procedure Manual for deputies involved in eviction procedure,

the following was noted:

This effort in April 2012, by Court and Civil Services civilian and sworn

supervisors is commendable.

There was no evidence of the date established or an approval by either the

Court and Civil Services Lieutenant or the Adult Detention Division Captain.



Recommendation:

It is recommended that Court and Civil Services’ policy and procedure directives or manuals be reviewed to determine if appropriate chain of command concurrence has occurred.

Finding No. 67 — Police Clergy

Various SCSD clergy members responded, making valuable contributions. Their efforts

were acknowledged by the Sheriff and the Police Psychologist. However, it was determined

that SCSD clergy members have not received formalized police trauma training.

Recommendation:

It is recommended that SCSD General Order No. 1.05, “Chaplaincy Program” be reviewed. Consideration should be given to including trained police clergy in SCSD’s trauma response program and determining if the order’s training requirements meet SCSD’s needs.

Finding No. 68 — Maintaining Original Paperwork

The Court and Civil Services’ original paperwork regarding Ferrario’s eviction was taken by

the deputies into the field. This paperwork was significantly damaged by the fire.

Recommendation:

The original paperwork should be maintained at the Court and Civil Services. This is a best practice that ensures immediate reference for tactical information and litigation protection.

Finding No. 69 — Risk Assessment

It was found that the Court and Civil Services’ Risk Assessment form requires change.

Although this form was revised after the incident, it needs further improvement.

Recommendation:

Consideration should be given to creating an information checklist. The checklist could be used to provide the deputies with animal, building, location, people, and vehicle information. This data should be followed by a criminal record check, firearm inquiry, and premise history search. As this form is developed, the lessons learned from this incident should be incorporated.



Finding No. 70 — Adult Detention or Operations Division

More than one SCSD employee recommended that Court and Civil Services field deputies

should be managed by the Commanding Officer of the Operations Division. The primary

reason cited was that Adult Detention supervisors and managers lacked patrol experience.

Recommendation:

The issue of patrol experience requires SCSD management review.

Finding No. 71 — Field Supervision

At the time of the incident, SCSD had one sergeant in the station and an acting sergeant for

field operations. Due to budget constraints, the absence of field supervision is a constant

challenge for California law enforcement agencies.

Recommendation:

When only one patrol sergeant is assigned to a patrol shift, SCSD must determine the value of the supervisor being assigned to the station or being present in the field. Many policing agencies are opting for field supervision, using deputies as acting sergeants to staff station supervisory duties.

Finding No. 72 — Rapid Response

Due to SCSD SWAT personnel having take-home police vehicles with their equipment

inside, they were able to make an immediate response. This was a factor in keeping

Ferrario contained by specialized personnel.

Recommendation:

This practice should continue.

Finding No. 73 — Warning to the Locksmith

No evidence was discovered that the eviction agent’s warnings on the Court and Civil

Services’ eviction paperwork were discussed with Locksmith Engert. When peace officers

are aware of threats, it is a best policing practice to ensure that community members are in

a safe location. Once peace officers have determined the area to be reasonably safe, only

then should community members be allowed to approach.

Recommendation:

The SCSD should evaluate and determine whether a policy is necessary for similar situations. Additionally, training should address this issue.



Finding No. 74 — “If the Suburban is there”

During the eviction agent’s efforts to contact Ferrario, the agent learned from neighbors

that “If the Suburban is there, Ferrario is there.” It could not be determined if this

information was passed to the Court and Civil Services Clerk.

Recommendation:

Court and Civil Services civilian and sworn personnel should receive training on extracting safety information from people who request civil process. Supervisors must ensure that information gained is evaluated and shared with all personnel involved in the activity.

Finding No. 75 — Department Changes

Prior to the report’s completion, it was determined that SCSD was initiating change as a

result of this incident. Due to the lessons learned, the statewide Civil Process Survey

initiated by Sheriff Christianson, employee feedback, and author recommendations, the

following changes have occurred or are in progress:

Ballistic Shields – Added to Court and Civil Services’ Vehicles

Court and Civil Services Vehicles – Equipped Same as Patrol Vehicles

Computer Systems – Installed in Vehicles

Protective Helmets – Issued

Vehicles – Purchased Three New Vehicles

Briefing Session – Formal Monthly Session Established

Threat Alerts – Court Bailiffs Identify and Share Danger Signs

Eviction Date and Time – Eviction Agent Directed to Not Share

Eviction Date and Time – Not Provided to the Tenant

Five-Day Notice – Modified to Reflect SCSD Arrival at 6:01 a.m.

Case Information – Scanned into Computer File

Risk Assessment Matrix – Modified for Civil Unit

Building Approach, Entry and Search Training – Being Developed

Rifle – Being Trained to Deploy

SWAT – Utilizing as a Training Resource

Recommendation:

The following should be considered:

Briefing – Change Frequency to Weekly Briefing – Include Court and Civil Services Civilian Personnel Briefing – Documented Agenda with Open Discussion



Court and Civil Services Orders and Protocols – Document in Manual Eviction Date and Time – Agent Sign Non-Disclosure Form Information Scanned – Develop Section with Guidelines Level Three-A Ballistic Helmets – Provide

Finding No. 76 — Psychological Services

Without properly trained and available trauma response personnel, natural reactions to a

critical incident are seldom acknowledged and understood. If not immediately addressed,

self-destructive behavior, poor work performance, termination, and suicide may occur.

It was commendable that the SCSD Police Psychologist was immediately involved. The

following contributed to the psychologist’s effectiveness and people’s welfare:

Sheriff’s Immediate Notification to the Psychologist

Previously Established Working Relationship

The comment “part of the SCSD team” by the Sheriff and other Department

members endorsed the psychologist’s organizational position.

Modesto Police Department’s Critical Incident Stress Management Team’s

(CISMT) Actions

Clergy Efforts

Recommendation:

The SCSD should maintain their effective partnership and working relationship with their police psychologist.

Finding No. 77 — Stress Management

As the incident continued, MPD’s Critical Incident Stress Management Team (CISMT)

assisted the SCSD Psychologist with individual and group debriefings. Their efforts created

a bridge for the most traumatized to connect with the police psychologist sooner rather

than later. Also, this provided timely opportunities for involved personnel to ask questions,

express frustrations, and share concerns.

It is known that a CISMT can immediately contribute to the recovery process by helping

people make sense of the tragedy and preventing further emotional trauma. Although it is

commendable that efforts are underway at SCSD to establish a CISMT, protocols, personnel

selection, and training have not been completed.

Recommendation:

The SCSD should finalize current efforts to implement a CISMT.



Finding No. 78 — Family Liaison

A SCSD deputy was assigned to the Paris family as a liaison. Later, family members thanked

the Department for handling the following tasks:

Coordinated with East Coast law enforcement to assist two relatives with

their drive to the airport.

Assisted a relative who had a brain tumor and was confined to a wheelchair.

Provided Deputy Paris’ badge to the family.

Handled numerous requests from family members during on and off-duty

hours.

Posted security at Deputy Paris’ home.

Worked with a family contact person to initially discuss issues.

Finding No. 79 — Funeral Requests

The family of Deputy Paris asked for specific considerations which the SCSD Sheriff

ensured were honored. These actions and concerns along with other SCSD efforts were

commendable.

Finding No. 80 — Viewing the Deceased Peace Officer

In this incident, Deputy Paris received multiple gunshot wounds. The SCSD Sheriff soundly

advised Deputy Paris’s relatives to consider not viewing his body as this would be a

difficult memory. This insight prevented additional trauma to those who wished to view

Deputy Paris. The Sheriff’s leadership is commendable.

Finding No. 81 — Neighbor Requests Entry

Shortly after Deputy Paris’ murder, SCSD personnel volunteered to secure Deputy Paris’

home. Since Paris lived alone, the SCSD wanted to ensure that no one would enter his

home prior to his immediate family’s arrival.

On one occasion, a trusted neighbor, who had been provided keys by Deputy Paris,

requested permission from the on-scene deputy to enter. This deputy wisely contacted a

lieutenant and was instructed to not allow entry. This was an outstanding decision as this

ensured the residence’s sanctity and security.



Recommendation:

In similar circumstances and prior to deployment, it is recommended that the supervisor of the assigned deputy discuss potential hypothetical situations that might occur.

Finding No. 82 — Peace Officer Death Responsibilities

After reviewing SCSD’s General Orders and General Order Number 1.03, “Death

Notification/Funerals,” it was discovered that a new order(s) should be created or the

current order amended.

Recommendation:

The amended or new order should contain a checklist for various ranks. The following should be considered:

Escorts – Immediate Family Members Family Liaison Officer – Assign Personal Belongings – Inspection and Protection Security – One Uniformed Officer Posted at the Victim’s House “Google Alert” – Approval of the Investigating Supervisor Note: A detective supervisor should insert the names of the involved criminal(s) and the victim peace officer(s) in an on-line “Google Alert.” This will result in an E-mail notification to the supervisor about Internet postings.

Finding No. 83 — The Victim Peace Officer’s Belongings

On Monday, April 16, 2012, three days after the incident, Deputy Paris’ desk and locker

contents were removed by a sergeant and a civilian supervisor. Department property was

returned and personal items were given to the liaison deputy for the Paris family.

Other than the order to clear the locker, the sergeant was given the assignment without

directions. Being unprepared for the potential emotional consequences from handling and

viewing Paris’ personal effects, the sergeant experienced an adverse emotional impact.

No consideration was given to securing the locker and office area from other employees

and completing an inventory. Fortunately, no one was present when this occurred.

Recommendation:

The following protocols are recommended for personnel removing Department and personal property from a peace officer’s briefcase, desk, duty or personal bags, duty or personal vehicles, locker, work space, etc.

A supervisor shall be assigned this task.



The superior officer assigning this task shall meet with the involved employee(s) before the inspection to discuss potential consequences, responsibilities, and strategies.

If someone within the agency has previously handled this activity or similar matters, they should be consulted.

Two people should handle this task. This ensures a witness to everything that occurs.

Involved employees should be cautioned of the significant potential for unanticipated emotional experiences.

The assigned supervisor shall be alerted to the possibility that items discovered may have an adverse impact on loved ones or the Department.

A superior officer shall be notified whenever improper items are discovered. This person shall make additional notifications to their chain of command.

Finding No. 84 — Employee Emergency Contact Information The SCSD’s database has automated and useful employee emergency contact information.

This system is commendable and the form is included in the addendum.

Recommendation:

The following information should be added to the form:

Clergy Information Current Assignment and Rank Date Information Entered Organ Donor Person designated to assist loved ones during an emergency.

Finding No. 85 — Funeral Expenses

The Stanislaus Sworn Deputies Association (SSDA) established a trust in memory of Deputy

Paris. Trust funds were used to pay for the funeral expenses. Furthermore, SSDA formed a

trust fund with other associations for Locksmith Engert’s family. These efforts are

commendable.



Finding No. 86 — Use of Lethal Force

During the critical incident, only one law enforcement officer used lethal force. Deputy

Paris’ partner fired rounds from a 40-caliber pistol. The deputy’s rounds were fired in

response to Ferrario’s gunfire. The Stanislaus County District Attorney determined the

deputy’s use of force to be justified.

Recommendation:

It is recommended that the SCSD find the deputy’s drawing, exhibiting, and discharging his firearm to be within policy. This is based on the deputy’s response to an immediate defense of life from gunfire that caused two deaths.

Finding No. 87 — Learning from Prior Events

Stanislaus County Sheriff Deputies cited an eviction that occurred in November 2001. At

this incident, gunfire was directed toward two landlords and SCSD deputies, wounding one

landlord. In response, lethal force was used.

During conversations with SCSD civilian and sworn employees, differences of opinion

existed as to whether the lessons learned from this incident were remembered. It was

apparent that some employees had forgotten how quickly police work can become violent.

Recommendation:

Law enforcement supervisors must consistently remind subordinate personnel to maintain their abilities, knowledge, and skills to effectively and safely respond to a wide range of policing activities.

Finding No. 88 — Civil Committee

A SCSD civilian supervisor with 35 years of law enforcement experience currently serves

on the California State Sheriff’s Association, Civil Committee. This person will have an

opportunity to share the lessons learned with this committee and implement change.

Recommendation:

A specific suggestion would be to enhance the officer safety information offered. It is recommended that this incident and the lessons learned be incorporated into the committee’s training programs.



Finding No. 89 — Statewide Survey

California is divided into 58 counties, each with an elected Sheriff. Prior to the report’s

completion, the authors recommended a survey of these sheriff agencies to assess their

civil process guidelines and practices. Commendably, the SCSD Sheriff initiated a statewide

civil process survey.

The SCSD Sheriff is working with the California State Sheriff’s Association to review the

survey’s findings. It is anticipated that this information will be shared with law

enforcement.

Recommendation:

As SCSD’s civil process assessment continues, it should be determined if the survey’s information can be helpful.

Finding No. 90 — Completing the Report

This report required accurate and relevant information. The availability and cooperation

of people to be interviewed and the completion of law enforcement investigative reports

were necessary to corroborate and refute facts. The following issues impacted the report:

Investigative Reports – The primary reports were not received until the

latter part of 2012.

Interviews – Months passed before a group of people agreed to be

interviewed.

Refusal to Interview – Some people refused to be interviewed, while others

initially declined and later agreed.

Trauma – The aftermath of violent deaths required time for some people to

process their feelings and determine whether they would be interviewed.

Public Safety Officers Procedural Bill of Rights – Issues needed to be resolved

with law enforcement agencies, employee associations, and attorneys.

Lethal Use of Force – Needed to be resolved prior to an interview.

Follow-Up Interviews – Some people refused a second interview.

Investigative Issues Unresolved – Pending further investigation, issues in one

report remain "open."

Corroborate or Refute – When information was offered, time was required to

verify if this was fact or opinion.



Finding No. 91 — The Sheriff’s Decision

Stanislaus County Sheriff Adam Christianson directed a “transparent analysis” of two

critical incidents. In the first incident, SCSD Crime Analyst Technician Mary Donahou was

accidentally killed in a traffic collision. Locksmith Engert and SCSD Deputy Paris were

murdered in the second incident.

Sheriff Christianson decided to utilize independent review to acknowledge what went right,

determine what went wrong, and ensure that best policing practices were utilized.

Furthermore, he was extremely clear in his direction to identify all lessons learned and

determine what changes are necessary.

Recommendation:

Independent review of a critical incident should continue to be an option for law enforcement leaders.



List of Findings with Page Numbers

Before the Incident Findings Finding No. 1 — Protecting His Castle 50

Finding No. 2 — Tactical Concerns Known and Reported 50

Finding No. 3 — A Problem was Brewing 51

Finding No. 4 — “Retirement Center” 51

Finding No. 5 — Patrol Experience 52

Finding No. 6 — The Eviction Schedule 53

Finding No. 7 — Supervisory Meetings 53

Finding No. 8 — Restricted Duty Status 54

Finding No. 9 — Documenting Performance 54

Finding No. 10 — Risk Assessment 54

Finding No. 11 — Warnings 55

Finding No. 12 — Data Bases 55

Finding No. 13 — Employee Data Base Suggestions 56

Finding No. 14 — Communicating with Dispatch 56

Finding No. 15 — Supervisory Attention to Field Activities 57

Finding No. 16 — An Appointment 57

Finding No. 17 — Follow-Up 57

Finding No. 18 — One Veteran to Another 58

Finding No. 19 — Educating our Stakeholders 59

Finding No. 20 — No Indicators 60



During the Incident Findings

Finding No. 21 — Watching the Police 61

Finding No. 22 —“I Think Someone’s In There” 61

Finding No. 23 — Rescues 61

Finding No. 24 — Rescue Training 63

Finding No. 25 — Rescuing Deceased People 64

Finding No. 26 — Information from Another Incident 64

Finding No. 27 — Private Armored Vehicle 65

Finding No. 28 — Radio Broadcasts/Transmissions 65

Finding No. 29 — Medical Emergencies 66

Finding No. 30 — Community Members in Harm’s Way 66

Finding No. 31 — The Right Decision 67

Finding No. 32 — Working Relationships 67

Finding No. 33 — Command Staff Teamwork 67

Finding No. 34 — Resources Impacted 68

Finding No. 35 — Command Post Location 68

Finding No. 36 — ICS Vests Not Worn by PD Personnel 70

Finding No. 37 — Peace Officer Bill of Rights 71

Finding No. 38 — Verifying a Caller was Ferrario 71

Finding No. 39 — The Caller was Ferrario 72

Finding No. 40 — Media Helicopters 72

Finding No. 41 — Press Information Officers’ Suggestions 72

Finding No. 42 — Initial Press Statement 73

Finding No. 43 — The Robot 74



After the Incident Findings

Finding No. 44 — Surrender was not an Option 75

Finding No. 45 — Ferrario Described as… 75

Finding No. 46 — Letter Corroborates Ferrario Behavior 75

Finding No. 47 — Explosives 76

Finding No. 48 — Origin of Fire 76

Finding No. 49 — Outstanding Public Safety Efforts 76

Finding No. 50 — Community Leadership 77

Finding No. 51 — The Investigation 77

Finding No. 52 — Working Effectively Together 78

Finding No. 53 — Communication Needs 79

Finding No. 54 — Court and Civil Services Radio Frequency 79

Finding No. 55 — Police Work is Dangerous 79

Finding No. 56 — Ballistic Protection 80

Finding No. 57 — Ballistic Helmets and Shields 80

Finding No. 58 — “Dragon Skin” 81

Finding No. 59 — Building Entry and Search Equipment 81

Finding No. 60 — Back-Up Deputy 82

Finding No. 61 — Court and Civil Services Training 83

Finding No. 62 — Tactics Training 83

Finding No. 63 — Introducing Startle and Surprise 83

Finding No. 64 — Working Together 84

Finding No. 65 — E-Learning 85

Finding No. 66 — Procedure Manual 85

Finding No. 67 — Police Clergy 86

Finding No. 68 — Maintaining Original Paperwork 86

Finding No. 69 — Risk Assessment 86

Finding No. 70 — Adult Detention or Operations Division 87

Finding No. 71 — Field Supervision 87

Finding No. 72 — Rapid Response 87



Finding No. 73 — Warning to the Locksmith 87

Finding No. 74 — “If the Suburban is there” 88

Finding No. 75 — Department Changes 88

Finding No. 76 — Psychological Services 89

Finding No. 77 — Stress Management 89

Finding No. 78 — Family Liaison 90

Finding No. 79 — Funeral Requests 90

Finding No. 80 — Viewing the Deceased Peace Officer 90

Finding No. 81 — Neighbor Requests Entry 90

Finding No. 82 — Peace Officer Death Responsibilities 91

Finding No. 83 — The Victim Peace Officer’s Belongings 91

Finding No. 84 — Employee Emergency Contact Information 92

Finding No. 85 — Funeral Expenses 92

Finding No. 86 — Use of Lethal Force 93

Finding No. 87 — Learning from Prior Events 93

Finding No. 88 — Civil Committee 93

Finding No. 89 — Statewide Survey 94

Finding No. 90 — Completing the Report 94

Finding No. 91 — The Sheriff’s Decision 95



The Future

Today, law enforcement personnel continue to encounter complex and dangerous incidents

that present serious threats to community members. Clearly, it is difficult to predict when

the people of California will experience our next critical incident where lives are

endangered. Unfortunately, there is no question that something will occur that will require

the immediate and safe response of California Peace Officers.

As this report was being prepared, a number of shooting incidents occurred throughout

our great nation. These senseless and violent shooting attacks included the following

tragedies:

Colorado Movie Theater – 24 Killed/58 Wounded

Wisconsin Sikh Temple – 6 Killed/4 Wounded

Connecticut School - 26 Killed/2 Wounded

New York Firefighters – 2 Killed/3 Wounded

Authors

This report was prepared by retired Los Angeles Police Captain Rich Wemmer and retired

Huntington Beach Police Lieutenant Ed Deuel. Rich and Ed are active members of the

California Commission on Peace Officer Standards and Training (POST), Law Enforcement

Officers Killed and Assaulted (LEOKA) Advisory Council. They have written critical

incident reviews for POST and have served as commentators, panel members, and subject

matter experts for POST Telecourses.

Rich and Ed have reviewed the deaths of over 500 California Peace Officers and

interviewed hundreds of law enforcement officers who have survived deadly incidents.

Collectively, they have 70 years of law enforcement experience and have trained thousands

of local, state, and federal peace officers throughout the United States. Both have been

recognized for their contributions to peace officer safety and training and acknowledged

for making peace officers more efficient and safer.

Rich is a recipient of the Lifetime Achievement Award for Excellence in Training by the

California Commission on Peace Officer Standards and Training in Sacramento, California.

Ed received the prestigious Golden Badge Award for his training contributions.



Addendum

Glendon David Engert Eulogy



Robert Lee Paris Jr. Eulogy

On Thursday April the 12th

we responded to a colleague’s call for

help, 11-99, shots fired, officer down, the last thing any one of us

wants to hear, was radio broadcast and suddenly we found

ourselves in a situation to where we couldn’t save Bob or Glendon.

My fellow Sheriffs, Police Chiefs, Law enforcement officers

from throughout the state and nation along with many other

dignitaries, officials for coming together today to honor Deputy

Robert Paris.

Deputy Robert Paris was also a hero to many,

compassionate in his service, thoughtful in his actions, dedicated to

his profession. He too, served his community and the Stanislaus

County Sheriff’s Office with honor and distinction.

Bob was our colleague, our friend and a member of our

family. He sacrificed his own life paying the ultimate price doing

what he loved to do, serving the community as a Deputy Sheriff.

Words can not express our pain and anguish over what’s happened

and we will never be able to understand this senseless act of

violence.

Today we honor Deputy Robert Paris but let’s not

forget the Engert family, the Gilinskas family, the Humble family,

our entire Sheriffs family, law enforcement families, first

responders and dispatchers and many others who not only placed

themselves in harm’s way but responded to our call for help and

supported us in our time of need.

On behalf of the men and women of the Stanislaus County

Sheriff’s office and on behalf of the entire law enforcement

community and on behalf of Bob’s family and friends everywhere, I

close, saying Bob thank you for making difference. We know you

are safe, may God bless you and your family. We will miss you, we

will never forget you and we will see you again my friend.

Sheriff Adam Christianson



Stanislaus County Sheriff’s Eviction Packet



Stanislaus County Sheriff’s Emergency Information Contact Form



Stanislaus County Sheriff’s 2012 Organizational Chart



Stanislaus County Sheriff’s Court and Civil Services Eviction Checklist



Stanislaus County Eviction Restoration Notice



Stanislaus County Notice of Eviction



Stanislaus County Notice of Restoration



Stanislaus County Notice to Vacate



Stanislaus County Writ of Execution



Whispering Woods Map

the eviction murders findings and recommendations · 2013. 2. 2. · shots fired 27 “11-99 on...

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